Coroner slams 'toing and froing' in mental health care of man who killed himself

A coroner has criticised a lack of communication and documentation in the care of a man who tragically took his own life.

David Alan Thornton had a long-standing history of mental health issues and had been sectioned in March of this year. The 45-year-old was subsequently moved between various mental health hospitals in Lancashire with one - the Calder Ward at the Royal Blackburn Hospital - being described by his family as "worse than a prison".

On June 20 of this year, David declined his parents' offer to go out for lunch, and when they returned that afternoon they found him unresponsive in their home. He was pronounced dead at the scene.

At an inquest coroner Kate Bisset criticised the "toing and froing" which David was subjected to. She said that while "David had acted impulsively" in taking his own life, his experience of mental health services "was not as it should have been".

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David, who regularly posted videos on social media highlighting the mental health benefits of fishing, was a lover of the the outdoors and was happy during his time at a mental health unit based in the former Calderstones in Whalley where patients have access to a large garden.

However, he was then moved to the Royal Blackburn Hospital on March 28, with the coroner reading from a statement by David's parents Linda and Alan: "His family couldn't understand why he had been moved, he wasn't well enough to agree to it or to challenge it. It was worse than a prison to him as he wasn't allowed outside. He wanted to return to Whalley."

David, from Preesall, was then moved back to Woodview at Whalley, where he stayed on the Greendale Ward for six days, before being allowed to return to his parents' home in Preesall, reports Lancs Live. However, David's mental health key worker failed to oversee his prescriptions, and at times he and his parents feared he would run out.

Don't suffer in silence

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CALM (0800 58 58 58) thecalmzone.net has a helpline is for men who are down or have hit a wall for any reason, who need to talk or find information and support. They're open 5pm to midnight, 365 days a year.

Greater Manchester Bereavement Service Greater Manchester Bereavement Service can help to find support for anyone in Greater Manchester that has been bereaved or affected by a death. No one needs to feel alone as they deal with their grief. www.greater-manchester-bereavement-service.org.uk

Childline (0800 1111 ) runs a helpline for children and young people in the UK. Calls are free and the number won’t show up on your phone bill.

PAPYRUS (0800 068 41 41) is a voluntary organisation supporting teenagers and young adults who are feeling suicidal.

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His mental health continued to deteriorate with his parents criticising the prescribing of one anti-psychotic drug - resperidone - for leaving him "dribbling from the mouth".

Ubaid Javed, a mental health nurse with Lancashire and South Cumbria NHS Foundation Trust (LSCFT), which provides mental health services, said that he could find nothing in David's records to explain why he was moved between so many different hospitals. Nurse Javed, who was not directly involved in David's care, said that this should have been documented and any new ward should contact the old unit for a handover. "There was nothing in the records to state what was handed over," he said.

At one point David revealed he had been hearing "hundreds" of voices and believed he was Gordon Ramsay. He also spoke of having spoken to the late Queen at Ascot and having a box implanted in his brain at the Kennedy Space Center.

LSCFT team leader Emily Eaton was asked about when David "came very close to running out of his medications - which caused him great anxiety". She admitted: "It was recognised that he had only been given 14 days. When a patient is put on new anti-psychotic medications they should be given a three-month supply and monitored for 12 months."

A review carried out after David's death found "lessons to be learned" regarding documentation and medication. This included an uncomplete care plan with Area Coroner Kate Bisset commenting: "How many inquests in the last month have I heard there was an incomplete care plan? I can think of at least three."

Returning a conclusion of suicide the coroner spoke directly to David's family and said: "I think you are absolutely remarkable people as a family. If I ever struggle with mental health I would count myself incredibly privileged to have a family like you. I often say that if clinicians communicated better, I'd be out of a job. However I can't say that if David had stayed in hospital the same would not have happened.

"I can't say that there is any area of care that could or should have been different which would have made a difference to David but that is not to say that I think your experience is as it should have been."