Keiran Toman
PFD Report
Historic (No Identified Response)
Ref: 2014-0225
Coroner's Concerns (AI summary)
Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk of deterioration, especially when patients disengaged without follow-up to next of kin.
View full coroner's concerns
(1) That some psychiatric staff and services may effectively collude with patients by acquiescing to requests not to pass on information to their families, when these decisions are taken by patients who have insufficient insight to make them_ (2) That the lack of contact with families in such circumstances may leave vulnerable patients isolated and increase their risk of deterioration and death, as occurred in this case and in others that have investigated_ (3) That some psychiatric staff may be insufficiently trained to assess the capacity of patients to decline contact with next of kin and thus the best interest of such patients is compromised_ (4) That where decisions are taken by psychiatric staff not to contact family in line with a patients wishes in order to try keep that patient engaged with services, that contact is still not made to the family or next of kin even when such a patient disengages from the _psychiatric services and and
(5) That permission to contact next of kin/ family decisions taken by patients may not be reviewed often enough by those providing psychiatric care, such that information in relation to changes in treatment; mental state , discharge, provider of care etc may not be appropriately communicated to the detriment of patients_
(5) That permission to contact next of kin/ family decisions taken by patients may not be reviewed often enough by those providing psychiatric care, such that information in relation to changes in treatment; mental state , discharge, provider of care etc may not be appropriately communicated to the detriment of patients_
Sent To
- Hafod Community Mental Health Team
- NHS England
Response Status
Linked responses
0 of 4
56-Day Deadline
7 Jul 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 Wednesday 5"h September 2012 commenced an investigation into the death Mr Keiran Michael John Toman 39 years: The investigation concluded at the end of the inquest on Wednesday #89ep April 2014. The conclusion of the inquest was: Medical Cause of Death Emaciation (a)
How, when and where and in what circumstances the deceased came by his death: Mr Toman suffered with drug induced fixed delusional disorder from 1998. This was treatment resistant; and Ied him to becoming socially isolated and self-neglecting and ultimately to his death: He was discovered deceased in his room at Hyde Park Tower Hotel on 23/7/2010. Conclusion of the Coroner as to the death Natural Causes
How, when and where and in what circumstances the deceased came by his death: Mr Toman suffered with drug induced fixed delusional disorder from 1998. This was treatment resistant; and Ied him to becoming socially isolated and self-neglecting and ultimately to his death: He was discovered deceased in his room at Hyde Park Tower Hotel on 23/7/2010. Conclusion of the Coroner as to the death Natural Causes
Circumstances of the Death
It was clear from the evidence taken during the inquest that Mr Toman suffered with fixed delusions into which he had no insight: He resigned form his job and cut all social contacts As part of his illness he then cut off contact with his family following his first psychiatric admission under Section 3 of the Mental Health Act in 2007 to Heatherwood Hospital, due to this lack of insight: Despite his lack of capacity to make such decisions, the psychiatric services subsequently involved in his care at Heatherwood Hospital, Wokingham CMHT and the Hafod Community Mental Health Team, North Wales, made no contact with his family, even when as part of his illness Mr Toman removed himself from psychiatric care and follow up. Mr Toman was thus left completely without support deteriorated until the point where he starved himself to death due to his paranoia and was found deceased in Hyde Park Towers Hotel by cleaning staff: It was the clear view of the senior psychiatrist from whom evidence was taken in this inquest;, that information should be shared with all those involved in the care of such patients including their families/next of kin
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action: It is for each of the parties to whom this Prevent Future Death Report is addressed to identify the matters of concern that they should respond to.
Copies Sent To
47 Peach Street; Wokingham, Berkshire_ RG40 1XJ Consultant Psychiatrist Hafod Community Mental Health Team being and Forge
Beechwood Road
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.