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Urgent referral ignored days before father hanged himself

A healthcare trust has apologised after a communication breakdown meant a man had taken his own life by the time an urgent referral to mental health specialists had been made.

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Trust apologises for communication failure before man's death

A health trust has apologised for communications failings in the handling of a man with depression who took his own life before mental health professionals could help him. A coroner heard how an urgent referral about Alvan Brown from Retford was faxed to the wrong number and ignored for five days.

Hours before it was received by the right team Mr. Brown had hanged himself.

Nottinghamshire Healthcare offers its sincere sympathies to the family and friends of Mr. Alvan Brown. We agree that on two occasions communication between services could have been better, but accept that this may not have affected the sad outcome for Mr. Brown.

We welcome the Coroner’s comments about the steps we have already taken to improve systems that would have flagged up Mr. Brown’s contact with more than one of our services. Dr. Chris Packham, Associate Medical Director for the Trust, gave extensive evidence to the Coroner about the improvements we have implemented and will continue to develop on improving this aspect of our care. This will be of small comfort to Mr. Brown’s family but will improve communications in the future.

– Nottinghamshire Healthcare NHS Trust

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