UK Inquiry Tracker

Anthony Preston

PFD Report Historic (No Identified Response) Ref: 2016-wp25351

Date of Report 11 August 2016

Coroner Robert Chapman

Coroner Area Rutland and North Leicestershire

Response Deadline ✓ from report 30 September 2016

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The discharge system lacked robustness, with no documentary proof of a telephone call to the Crisis Team, and no immediate follow-up notification of discharge; the coroner noted this left a high-risk patient without support.

View full coroner's concerns

(1) Mr Preston had demonstrated, in his early return from home leave in the first few days of November, that living at home was a source of substantial stress, and likely to cause him severe anxiety and deepen his depression.

(2) The system for discharge of patients, whereby a nurse makes contact with (in this case) the Leicestershire Crisis Team does not appear to have been robust. There was no documentary proof of the telephone call.

(3) There was no immediate follow up by e mail or fax to the Crisis Team to notify the discharge, and the fact that Mr Preston was at high risk because of the anxiety created when he was living at home.

(4) As a result, Mr Preston and his main carer at a time when he was at high risk. ACTION SHOULD BE TAKEN: were left without support The Priory hospital and the Leicestershire Partnership NHS Trust should review the discharge procedures. It would be appropriate to have a system in place to ensure that there is documentary proof of any telephone call, and importantly, written notice by way of e mail or fax of notification of discharge that is sent immediately upon, or prior to, the patients discharge. This will enable consideration of the appropriate arrangements to be put in place for the follow up.

Part of a Series

2 separate reports were issued from this inquest, each sent to different organisations.

2021-0319
Sent to: Essex PoliceNational Police Chiefs’ Council

No responses yet

This report (2016-wp25351) is shown above.

Sent To

Leicestershire Partnership NHS Trust
Priory Hospital, Cheadle

Response Status

Linked responses 0 of 2

56-Day Deadline 30 Sep 2016

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 28 July 2014 I commenced an investigation into the death of Anthony John Preston. The investigation concluded at the end of the Inquest on 27th July 2016. The conclusion of the inquest was: The Cause of death was:
1.a. Hanging The Conclusion of the Coroner was: Mr Preston killed himself

Circumstances of the Death

Mr Preston had been suffering from mental health problems for a short period in the summer and autumn of 2013. On the 17 October 2013 he was admitted to The Priory Hospital in Cheadle, and remained there as a voluntary patient until the 11 November 2013. He was under the care of In early November he was granted home leave for a few days. The leave was not successful and he returned early to the hospital. It was clear that home leave was a time of great stress to Mr Preston. On the 11th November he was discharged to his home, and into the care of the Crisis Team in his home area of Leicestershire. gave evidence at the Inquest that the system upon discharge was for a nurse at the Priory to speak to a nurse in the Crisis team in Leicestershire, to send a fax to the GP indicating discharge and the medication prescribed, and it was to be followed up with a discharge letter. There was no documentary proof of either the telephone call to the Crisis team, of any fax, and the only document available was a discharge letter to the GP that was sent on the 27 November, two weeks after discharge. The Crisis team denied that they had received any notification, telephonic or otherwise, of Mr Preston's discharge. In consequence:
1. The Leicestershire Crisis Team were unaware of his discharge
2. Therefore, they did not arrange any follow up by the Crisis Team
3. After a few days at home Mr Preston became extremely anxious and depressed had to contact a mental health professional to request that he and see Mr Preston, which he did immediately, and arranged a Mental Health Assessment.
4. This resulted in Mr Preston being admitted to The Bradgate Unit in Leicester on the 15th November, 4 days after leaving The Priory.

In May 2014 Mr Preston hanged himself. It is not suggested that there is any causal connection between his death and the discharge arrangements from The Priory.