Oxford Health NHS Foundation Trust

5. Dr V complains a Trust psychiatrist opened and deleted an email she sent on 22 July 2022, in which she expressed concern about her husband, Dr R’s behaviour and made a plea for help. She complains she does not know when the email was opened and deleted, whether before or after her husband’s death. Dr V also complains about the psychiatrist’s appearance and demeanour at the Inquest on 15 and 16 October 2024.

6. Tragically, Dr R took his own life on 12 October 2022. Dr V says this could have been prevented and Dr R would still be here, if the psychiatrist had acted upon and responded to her email. Dr V says she is left in distress not knowing whether the psychiatrist chose to disregard her family’s wellbeing which would be demonstrated if he had opened and deleted the email before Dr R’s death, or whether the psychiatrist acted to cover-up his wrongdoings which would be demonstrated if he deleted the email after Dr R had died.

7. Dr V is left devastated by the death of her husband and has been caused considerable distress by not knowing the timing of the email’s deletion and by the psychiatrist’s appearance and behaviour at Inquest.

8. To resolve her complaint, Dr V wants to know when the psychiatrist opened and deleted the email. She would like the psychiatrist to be placed under the supervision of his responsible officer, and she wants the Trust to implement a system to ensure all emails are seen by a second person.

13. Dr R saw the Trust psychiatrist twice in 2021. The psychiatrist considered Dr R had a moderate severity depressive disorder and prescribed him medication.

14. Dr V says her husband’s mental health deteriorated in the spring of 2022. She explains he was suspended from work in April 2022 and his behaviour became increasingly bizarre and unusual, on occasion resulting in violent outbursts.

15. Dr V says in desperation, she emailed the psychiatrist on 22 July 2022, describing what was happening and stating her hope that the psychiatrist would assess Dr R. She did not receive any response from the psychiatrist.

16. Dr V says Dr R deteriorated further and in September 2022, he allowed her to access GP services on his behalf. This resulted in a GP referral, and an appointment was made for Dr R to see the psychiatrist.

17. Tragically, Dr R took his own life on 12 October 2022. This happened before the scheduled psychiatry appointment.

18. The coroner’s inquest was held on 15 and 16 October 2024 and the psychiatrist attended to give evidence. Dr V then complained to the Trust. Remaining unhappy with the responses she received Dr V asked us to consider her complaint.

The email 21. Both Dr V and the Trust agree that her email was opened and deleted. In response to her complaint, the Trust said the psychiatrist could not remember receiving, opening or deleting it, but he accepts he must have clicked onto and deleted the email. There is no contention or challenge to this claim, and as such it does not require Ombudsman investigation to resolve any further.

22. What is left for us, is to consider the claimed impact. Dr V says if the psychiatrist had responded to her email, her husband may still be alive today. When speaking with her, Dr V told us Dr R had stopped taking his medication. She said had the psychiatrist responded to her email, had Dr R been seen and had he been admitted to hospital, he wouldn’t have died.

23. We recognise how strongly Dr V feels that her husband’s death could have been prevented if the psychiatrist had acted upon her email. For us to reach our own robust and independent view, we would need clear evidence to link the issue to the impact being claimed. Even for us to take a view using the balance of probabilities, we would still require a strong evidence-base to do so. We do not see anything to indicate that we would be able to do so here.

24. We cannot know what might have happened, even had the psychiatrist responded to Dr V’s email. We cannot know if Dr R would have accepted or complied with any offer of psychiatric appointment at that time. We cannot know this would have led to hospital admission. We cannot say that even with further psychiatric input, the very sad course of events would not have happened.

25. We know that owing to Dr V’s continued efforts in seeking help for her husband, he did have an appointment secured with the psychiatrist, which he knew about before his death. Even with this in place, very sadly, Dr R died.

26. Having considered this very carefully, we do not see there would be anything to indicate to us, that we could attribute Dr R’s death to the lack of response from the psychiatrist to Dr V’s email.

27. We move on to consider the timings. Dr V complains she does not know when the email was opened and deleted, whether before or after her husband’s death. In response to her complaint, the Trust said it had contacted Microsoft, the provider of its email services, and their response was as follows: ‘Message trace is designed to track email activities within a 90-day period. Beyond this duration, the data is no longer available for retrieval’.

28. The Trust said its understanding is that it was possible for Microsoft to confirm that the email was received, opened and deleted but not to provide a date or time, and it apologised to Dr V that it could not provide any further information on this.

29. We have considered Microsoft website information on the message tracing system. This explains how a user can ‘query up to 90 days of historical data’ and ‘specify date/time ranges up to 90 days’. We are now over three years since Dr V sent the email in question and a year and eight months on from the pre-inquest hearing when Dr V was advised the email had been opened and deleted.

30. We cannot see that we would be able to find any evidence to resolve this issue for Dr V. For this part of her complaint, she has come to us seeking knowledge of the date(s) when her email was opened and deleted. We see nothing to indicate that we could ever achieve this outcome for her. We recognise how disappointing this outcome will be and we are sorry for any understandable upset caused as a result.

The psychiatrist at inquest 31. A coroner is an independent judicial officer who investigates deaths reported to them. An inquest is a medical/legal enquiry conducted by the coroner, into the circumstances leading up to the death of the deceased. This is considered a formal judicial process.

32. The Trust psychiatrist attended and gave evidence at inquest. Dr V’s complaint is with the manner of his dress as well as his conduct and demeanour, when giving evidence.

33. The evidence being given at inquest is being presented in a legal process and does not form part of the normal duties of an NHS staff member. It is for the coroner to determine whether the testimony of witnesses is credible. In turn, it would be for the coroner to determine or raise any concern with the psychiatrist’s appearance or manner at the time of his attendance in their court.

34. For this reason, concerns about the manner of the evidence given at an inquest needs to be raised in that forum as these concerns fall outside of our remit as set out in the HSCA, the Act that governs our work. For this reason, we cannot consider this part of Dr V’s complaint further.

1. We carefully considered Dr V’s complaint, particularly that she says her husband would still be alive today if the psychiatrist had responded to her email. We do not consider we could attribute Dr R’s death to the lack of action or response to Dr V’s email. We do not see anything to indicate that we could link this claimed failing to the claimed injustice.

2. Regarding when the email was opened and deleted, we do not see anything to indicate that we would be able to resolve this for Dr V. We would not be able to achieve the outcome she seeks for this issue, of knowledge of those dates.

3. When the Trust psychiatrist gave evidence at inquest, this was done as part of a judicial, legal process and did not form part of his normal duties of an NHS staff member. Dr V’s complaint about his appearance and demeanour is outside of our remit to consider.

4. For these reasons, we have decided not to investigate the complaint further. We were very sorry to have learned of the reasons for Dr V’s complaint. We recognise how important this complaint is to Dr V, and how significantly she has been affected by these events. We thank her for sharing the details of the complaint with us and hope this statement clearly explains our decision.