A forklift driver found hanged in his home committed suicide after health services failed repeatedly “to fully assess his mental state”, an inquest found.
Leon Evans, 36, was discovered hanged at his home in Becontree Avenue, Dagenham, on September 11 last year.
Walthamstow Coroner’s Court heard last week that he was under the care of the borough’s mental health trust in June 2017 after showing signs of depression and psychosis following a bereavement.
During the next three months he tried to end his life several times and spoke of hearing voices. He told his GP of regularly taking cannabis and cocaine, habits that reportedly stopped when the voices began.
Sectioned in July 2017 after a suicide attempt, his consultant at Goodmayes Hospital in Ilford discharged him after three days without seeking the views of his family.
“The evidence heard suggests that had Leon’s mother been asked for her view and had she expressed concerns about discharge, the consultant would not have discharged Leon,” said senior coroner Nadia Persaud.
She said “there was no clearly documented risk assessment” at the time of his discharge, with Leon considered “low risk” of harm to himself.
Leon’s mother confirmed she did not have any contact with the Goodmayes team until she went to collect her son. A doctor told her he was “not that bad”: she was not asked what she thought.
After his discharge he came under the care of the Home Treatment Team and later the Community Review Team, both under North East London NHS Foundation Trust (NELFT).
No joint assessment took place during the handover, as it should have done: the meeting was cancelled at the last minute due to staff shortages and never rearranged.
Between August 14 and 20 Leon was not assessed regularly enough given his risk of harm, the court heard. He was only checked after ending up in hospital twice on August 20, the second occasion for an attempted overdose on painkillers.
A care plan put in place the following day was not followed and steps were not taken to provide Leon with a sickness certificate for work or arrange urgent psychological therapy. His risk of harm was stepped down two weeks later even though medical teams had not assessed his mental state.
No face-to-face contact with Leon took place the week before his family members discovered his body.
An unsent message on his phone to his girlfriend mentioned being sorry for what he was about to do and feeling “so drained”.
Post-mortem tests carried out three days later found no suspicious injuries and gave the cause of death as 1A suspension. There were no illegal drugs in his system, toxicologists reported.
Returning a narrative verdict, the coroner said: “His death was contributed to by a failure of the mental health services to fully assess his mental state, to fully assess his rick of suicide — by gathering, considering and sharing key clinical information — and to put in place and carry out robust management to address the risk.”
She postponed a prevention of future death report to give the trust six weeks to present evidence of changes introduced in the wake of his death.
Describing Leon as “loud”, “happy-go-lucky” and “sorely missed”, his mother Elaine and partner, Victoria, said in a statement: “We tried to get Leon help but feel we were not listened to.
“If more had been done by mental health services we believe Leon would still be with us today. The trust has indicated that they have learnt lessons from Leon’s death and we hope as a result another family will not have to go through what we have been through.”
Their solicitor, Clair Hilder, added: “Leon was allowed to fall through the gaps in the mental health service that simply wasn’t functioning to keep a vulnerable man safe.”
A spokesman for the trust said: “We would like to extend our sincere condolences to the family and others affected by this tragic death.
“As an organisation, we always seek to improve our services based on patient and families experience of our services.
“We will be updating our Community Recovery Team policy in light of the shortcomings identified in the coroner’s conclusion.”
For confidential help and support you can contact the Samaritans on their free helpline 116 123.
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