Graham Darby

PFD Report Historic (No Identified Response) Ref: 2014-0367
Date of Report 24 July 2014
Coroner Gail Elliman
Coroner Area London North
Response Deadline est. 18 September 2014
Coroner's Concerns (AI summary)
A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.
View full coroner's concerns
That there were a number of agencies involved in both trying to assist Mr Darby and to deal with his anti-social behaviour (which led to the eviction). That although information was passed on generally between agencies and that communication was ongoing about Mr Darby, the evidence disclosed that one significant piece of information was not flagged up as it was not made sufficiently clear to Family Mosaic who were responsible for his housing and eviction. This was that the psychiatrist from ARC made a specific observation that Mr Darby had said that he had a knife and a rope in his property and would take his own life if evicted. The witness from Family Mosaic said that this particular piece of information was not passed on and that if it had been different actions may have been taken. Such direct threats should be flagged up in similar circumstances.
Sent To
  • East London NHS Foundation Trust
  • Family Mosaic
  • Hackney Alcohol Recovery Centre
Response Status
Linked responses 0 of 3
56-Day Deadline 18 Sep 2014
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 24 June 2013 I commenced an investigation into the death of Graham Darby, born on 18 July 1956. The investigation concluded at the end of the inquest on 31 October 2013. The conclusion of the inquest was that the medical cause of death was suspension by ligature and that his death was a suicide.
Circumstances of the Death
I concluded that Graham Darby had a mental and behavioural disorder due to alcohol dependence and that the day after having been evicted from his home he was found dead at his home address having forcibly re-entered the property.
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Community mental health services for violence-fixated children
Southport Inquiry
Mental health access for alcohol addiction
Mental health assessment powers for isolated children
Southport Inquiry
Mental health access for alcohol addiction
Pre-1996 Transfusion Testing
Infected Blood Inquiry
Incomplete GP Patient Data Transfer
New Patient Registration Screening
Infected Blood Inquiry
Incomplete GP Patient Data Transfer
Independent review of use of force on mentally ill detainees
Brook House Inquiry
Mental health access for alcohol addiction
Separate SIO and Family Liaison Officer roles
Daniel Morgan Panel
Emergency family notification
Patient Transfer Protocol
Hyponatraemia Inquiry
Incomplete GP Patient Data Transfer
GP Notification of Death Circumstances
Hyponatraemia Inquiry
Emergency family notification
Candour about harm
Mid Staffs Inquiry
Emergency family notification
Death in Custody Checklist
Baha Mousa Inquiry
Emergency family notification

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.