Suicide at Beachy Head could have been avoided

Beachy Head SUS-140220-154006001
Beachy Head SUS-140220-154006001
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A mental health organisation was criticised at the inquest of a man who committed suicide at Beachy Head.

Lee Churcher, 49, of Hartfield Road, died on May 6 at Beachy Head. He was due to been seen by Health in Mind, which is part of the Sussex Partnership NHS Foundation Trust, after a referral by a criminal justice liaison nurse on April 10.

He had been arrested for being drunk and disorderly and had expressed thoughts of suicide and depression. But by the time an appointment was picked, Mr Churcher had died.

An inquest into his death, heard Michelle Hall, a criminal justice liaison officer, saw Mr Churcher in custody on April 10, after his arrest for drunk and disorderly behaviour.

She referred Mr Churcher to Health to Mind on a non-urgent basis, meaning an appointment should be made within 28 days.

The case was then classed as urgent by a health worker at Health to Mind, but it was changed back to non-urgent by a consultant. Coroner Alan Craze said the health worker, who had not seen Mr Churcher, must have changed the case to urgent for a reason.

He said, “She was subsequently asked what her reasons were... in fact he had said he had been on his way to Beachy Head and couldn’t see any light at the end of the tunnel.”

But Matthew Phillips, of Health to Mind, told the inquest the referral notes did not suggest it should be an urgent case, and that Health to Mind does not deal with people in crisis.

“In primary care, the onus on us is to see lots of people and treating common mental health problems,” said Mr Phillips. “For that reason we can’t see people the next day, or even in seven days in some cases.”

But coroner Mr Craze said, “I can’t help thinking that it would be far better in this case if there had been a system where Lee could have been seen immediately. Michelle Hall sees him on the April 10. The death is on May 6. You’re telling me no referral letter was written or sent until after the death?”

The Sussex NHS Partnership Trust, which runs mental health services in the area, said lessons had been learnt, but Mr Churcher’s mother said, “It does not bring my son back.”

Mr Craze said, “I do not think you’re doing the best you can for your patients, if not only are they not seen in a timely way, but significantly no appointment has been even made. It should have been an urgent referral and it is possible he would not have died if that had happened.”

A Trust spokeswoman said, “Our thoughts and sympathies go out to this person’s family at this difficult time. As mentioned at the inquest, we assessed him, referred him to his GP and were in the process of arranging for him to receive psychological therapy. If clinical staff had judged him to need more urgent treatment we would have arranged this. We have conducted a full investigation into what happened and are looking at whether any changes are needed to our referral and triage processes.”