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Kent and Medway NHS and Social Care Partnership Trust admit failings after Sittingbourne man's death

A coroner has said opportunities were missed to help a man battling mental health and alcohol problems.

Richard Avron-Cotton, who had previously been diagnosed with bipolar, was found at his home in Cherry Close, Milton Regis, on June 12 last year.

Archbishop's Palace in Maidstone. Stock image
Archbishop's Palace in Maidstone. Stock image

The 34-year-old's family told the court he would appear well-dressed for interviews as he was afraid of being sectioned after being detained in 2006.

Coroner Katrina Hepburn said: “He had a fear of getting locked up. When he went to meetings he’d make a massive effort to be tidier.”

In June 2016 he was referred to mental health specialists after he said he saw demons and was hearing things having previously being diagnosed with mental and behavioural problems due to alcohol.

In August he referred himself to the drug and alcohol rehabilitation service Turning Point for his level of drinking and stayed in contact until March 2017 when the contract changed hands to Forward Trust.

He had also failed to attend a number of appointments with his care co-ordinator but would often turn-up unannounced when he felt he was able to.

"He'd make a massive effort to be tidier" - Coroner Katrina Hepburn

Although he was reviewed by a mental health team, it was done in a way which was not consistent to notice a deterioration in his condition.

He was not seen by his usual care co-ordinator, Julian O’Shea, after March 2018 which was a missed opportunity to spot his worsening condition.

The coroner said: “He was seen by a stand-in care co-ordinator and she may not have known the background.”

After he did not attend his appointment, Mr Avron-Cotton was offered another one in May, which he also missed, and again in June, days before his death which he also did not attend.

Mr O’Shea said a plan was put in place to visit him at home but he died before it could be done.

"He had a fear of getting locked up" - Coroner Katrina Hepburn

Mr Avron-Cotton also asked staff not to visit him at home which, the coroner added, was another missed opportunity to investigate his wellbeing.

The court heard how a 'did not attend' policy was not properly followed.

Coroner Katrina Hepburn said: “I don’t know the exact reason for the deterioration in Richard’s mental health.”

Using a narrative conclusion, at Archbishop's Palace in Maidstone, she added: “Richard Avron-Cotton was found by his father having died at his home on June 12, 2018.

“He died as a result of an alcoholic cardiomyophathy following alcoholism, a condition developed to cope with mental health problems.”

"He died as a result of an alcoholic cardiomyophathy" - Coroner Katrina Hepburn

A Kent and Medway NHS and Social Care Partnership Trust spokesman said: "We were deeply saddened by Richard’s death and offer his family and friends our most sincere condolences.

"An internal review was carried out to identify areas where we could and should have done better in Richard’s care.

"As a result, we have strengthened our approach across a number of areas including how we respond when people miss appointments.

"We will continue to review the changes made to ensure that they are sustained."

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