Published: 00:01, 06 March 2015 |
Updated: 09:42, 06 March 2015
Ryan Males, 22, of Earlsworth Road, Willesborough, was classed as medium to low risk, despite a history of self-harming.
And a review of the case after his death concluded that he should have been classed as high risk, the inquest heard.
The mistake was made at a time of staff shortages and people in Mr Males’ category being kept on a waiting list.
Christine Freedman, assistant coroner for Central and South East Kent, recorded a verdict of suicide, but said Mr Males should have had more help.
“There was a crucial failing to recognise the degree of risk. The underestimation was compounded by the staff shortages in the team at the time" - Christine Freedman, assistant coroner
She said: “There was a crucial failing to recognise the degree of risk. The underestimation was compounded by the staff shortages in the team at the time.
“He took his own life by leaping from a tall building.
“We know of missed opportunities to intervene, but I cannot say intervention could have made a difference to the outcome.
“It is a tragedy Ryan didn’t get more help but we can’t say it would have stopped him doing what he did. But it’s a shame we didn’t have the opportunity.”
Mr Males leapt from the Panorama apartment building last October.
Helen Burns, operational team leader for Ashford’s Community Mental Health Team, reviewed the case after the tragedy.
The team had classed him as medium to low risk after an assessment so he was kept on a waiting list, the inquest heard.
She said of Mr Males’ behaviour, including travelling to the notorious Beachy Head suicide spot in Sussex: “That is quite significant. It is very high-risk behaviour."
Mrs Freedman asked her: “The risk rating here was medium to low. In your view is that appropriate?”
Ms Burns said: “No, I would say his risk was high.”
She added the team was short staffed at the time, but said if fully manned nobody would be on a waiting list for a care co-ordinator.
She said if Mr Males had been classed as high risk he would have been allocated one within two weeks and been monitored.
Ms Burns added that the team was now back to a full complement of senior staff so patients were now getting the care they need. She added: “We now have robust screening and assessment.”
Mrs Freedman said because of the improvements she now did not feel the need to write to health chiefs raising concerns.
She said: “The systems are far more robust. I trust they will remain robust.”
Foster mother Tracy Roberts asked Mr Males’ GP why he had not been sectioned.
The inquest heard that on October 10, four days before Mr Males last saw Dr Nabin Kumtaboth corr, he had gone to Beachy Head with the intention of jumping off the cliff.
“I urge anyone who has cared for, or who is still caring for, someone with mental health problems, who believes their loved one has been incorrectly assessed as low, medium or no risk, to contact a local advocacy service who will help you get the help needed" - Foster mother Tracey Roberts
Ms Roberts told the doctor: “He had recently had an episode of suicidal intent. Why did you not section him?”
Dr Kumta, of the Willesborough Health Centre, said he felt Mr Males did not seem at that sort of risk the day he saw him – five days before he was found dead.
He would only be assessed by his state of mind at the time of the consultation, not before.
The doctor told Ms Roberts: “He was embarrassed and said he wouldn’t do it again. I knew he had harmed himself in the past, but it was not an urgent assessment at that time.”
Dr Kumta said that in his previous consultancy with Mr Males, on September 17, he had prescribed him a different set of anti-depressants because the previous ones had left him feeling “flat”.
At that consultation he was not seen as being suicidal.
Dr Kumta said Mr Males had been his patient since 2009 and straightaway he saw he had mental health issues.
He said that Mr Males did not underplay having suicidal thoughts.
The GP said: “He was open about how he felt. He was always someone who spoke clearly about how he was feeling.”
Speaking after the inquest, foster mother Tracy Roberts said she was disappointed that no action will be taken to safeguard others like Ryan.
She said: “I’d like to be clear on my concerns about Ryan’s lack of care and how this may still be impacting on other people in a similar situation.
“No action has been taken, or ordered by the coroner, to safeguard anyone assessed prior to Ryan’s death.
“This means that if it had been someone else who had died, then Ryan’s incorrect risk assessment would still not have been identified and he still would have died.
“Who is to say this hasn’t already happened, or is about to, as no one has looked into it.
“I urge anyone who has cared for, or who is still caring for someone, with mental health problems, who believes their loved one has been incorrectly assessed as low, medium or no risk, to contact a local advocacy service who will help you get the help needed.
“Ninety people a week in England and Wales take their own life and I find this shameful. With the right support it has been proven it can be successfully reduced.”
She described health service budget cuts as “nonsensical and lethal”, adding: “They have already resulted in a services shortage crisis, which I’ve no doubt cost Ryan his life.”
Ms Roberts said she was very proud of Ryan, who “suffered so bravely for so long despite being let down over and over again by medical professionals who were meant to help him.
"In Ryan’s name I will be looking at what further action to take to make sure this doesn’t happen to anyone else”.
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