Stephen Atherton died on 16 2013, aged 27. On 21 May 2013 an Investigation was commenced into his death: The investlgation concluded at the end of the inquest on 101 October 2014. The conclusion of the inquest was narrative and the medical cause of death was severe head injuries following a fall from height This resulted from the consequences of steroid-induced mood alteration, This steroid medication was being used in the management of metastatic neuroendocrine carcinoma (see attached):

Mr Atherton developed shoulder pain towards the end of 2012. At visits to A&E and his GP practlce this was attributed to his work as a brick layer: He re-presented to his GP in January 2013. An X-ray of his shoulder demonstrated an abnormality, which the reporting radiologist recommended should be further evaluated by a bone scan. This investigation was requested by his GP and a referral was made to the orthopaedic department at the Royal London Hospital (RLH): The results of this scan demonstrated findings in his chest, which warranted further investigations that could not be requested by the GP (a CT and MRI): A fax was sent by the GP to the orthopaedic department, requesting that the date of Mr Atherton's 'choose and book' outpatient appointment be brought forward from late March, given the results the bone scan: This fax was either not received by the orthopaedic department, or receivedt but not scanned into Mr Atherton's notes. The GP was not able to demonstrate that the fax was successfully delivered: In early March 2013 Mr Atherton developed problems with his speech_ He was referred to the on-call medical team at the RLH and was subsequently diagnosed with a metastatic neuroendocrine carcinoma He underwent chemotherapy treatment: He was also found to have metastatic tumour deposit his brain, which resulted in referral to the neurosurgical department at RLH: Mr Atherton undenwent removal of the metastatic brain tumour in early May 2013. As of the post-operative managementplan he was put onto reducing dose of steroid medication. His treating neurosurgeon was aware f the potential contribution this was having_on MrAtherton's Jw mood but it was felt that he was safe_to be_discharged on 13] May partt

2013. Two days later he began displaying unusual behaviour and expressing suicidal ideation to his partner: He was brought to A&E at RLH where he underwent a CT scan 0 his head: This demonstrated expected post-operative findings only: There were delays him being seen by the neurosurgical registrar, after which he was admitted t0 the ward, having been in A&E for almost seven hours: The registrar had discussed Mr Atherton's case with his neurosurgical consultant and the plan was for an urgent psychiatric assessment, given the history of suicidal ideation_ Following a handover process to a neurosurgical senior house officer (SHO) and from tha SHO to the night SHO, the urgency of the psychiatry referral and the of suicidal ideation was not communicated: As such no referral was made on 15 2013_ The following moring Mr Atherton had a further episode of unusual behaviour: He asked g0 to the ward television room and was accompanied by a healthcare assistant (HCA): However; he subsequently managed to leave the ward, contrary t0 the efforts of the HCA The hospital security staff and police were informed following this incident. However; Mi Atherton was found shortly afterwards, having fallen to his death at a nearby residentia housing block:

In my opinion action should be taken to prevent future deaths and believe the addressees have the power t0 take such action: