Jamie Barlow

PFD Report Historic (No Identified Response) Ref: 2014-0153
Date of Report 7 April 2014
Coroner Peter Dean
Coroner Area Suffolk
Response Deadline est. 2 June 2014
Coroner's Concerns (AI summary)
There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health assessment framework for high-risk patients.
View full coroner's concerns
The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working, clarity when police assistance was sought in respect of exactly what they were being asked to do, a need to look at the processes operating here, and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public. 2
Sent To
  • Norfolk and Suffolk NHS Foundation Trust
  • Suffolk Constabulary
Response Status
Linked responses 0 of 2
56-Day Deadline 2 Jun 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 28th of August 2012 I commenced an investigation into the death of Jamie Raymond Barlow, aged 29. The investigation concluded at the end of the inquest on the 25th of March 2014. The conclusion of the inquest was that Jamie Barlow took his own life.
Circumstances of the Death
Jamie had been a patient of the Suffolk Early Intervention in Psychosis Service and had previously been discharged from the service having appeared to make progress and to have reasonable insight. The General Practitioner then contacted the service again having had an unusual phone call from Jamie in which he had claimed to have drunk bleach 10 days earlier (though whether this had, in fact, happened was questioned medically at the time and was not certain) and was expressing other comments that caused concern. There was not felt to be a need to see him as an emergency that day, but there were clearly communication problems about the plans that were then made for a subsequent assessment of Jamie. Jamie then failed to attend an appointment at the GP’s surgery. The Mental Health Services were concerned about visiting him at his home, as there had been mention of him having weapons there, and police were not willing to conduct a welfare check without mental health personnel accompanying them as, based on the information they were given, they believed it might exacerbate the situation. Sadly, Jamie’s body was found hanging some days later, in the area of his home but not easily visible.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.