Coroner raises concerns after Northamptonshire dad took his own life weeks after referral to urgent care team refused
A senior coroner has raised concerns over the death of a Northamptonshire dad, whose referral to an urgent care team was refused just weeks before he took his own life.
Shaun Hall, aged 36, took his own life in December 2023 after struggling with his mental health.
A Prevention of Future Deaths report, published on Friday (January 31), has been sent to the Northamptonshire Healthcare Foundation Trust (NHFT) over concerns that similar deaths may occur in the future unless action is taken.
The trust has said it is preparing a formal response to the coroner and would like to extend its “deepest condolences to the family in this tragic case”.
Senior Coroner for Northamptonshire, Anne Pember, heard that Mr Hall suffered with mixed anxiety, depressive disorder and emotionally unstable personality disorder. He attended A&E at Northampton General Hospital in early November 2023 having taken an intentional overdose.
On the advice of his GP, Mr Hall self-referred to NHS Northamptonshire Talking Therapies later that month. A telephone assessment took place on November 20, 2023.
The assessment identified “escalating factors” around Mr Hall not being allowed to see his children. He reportedly stated that if he was not allowed to see his children he would take his own life.
The report noted: “The Mental Health Support Practitioner was so concerned at Shaun’s presentation that she made a referral to the Urgent Care and Assessment Team the following day. The referral was declined.
“Mr Hall was subsequently found deceased in the grounds of Whittlebury Hall on December 14, 2023.”
“Grave concern”
Ms Pember wrote: “During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken.”
She also expressed “grave concern” that the identity of the person at the urgent care and assessment team who declined the referral is not known and no notes were made of the referral.
Ms Pember warned that action should be taken to prevent future deaths and that the healthcare trust “have the power” to do so.
A spokesperson for Northamptonshire Healthcare NHS Foundation Trust said: “As a trust, patient safety is our highest priority and it is really important to us that we learn lessons from incidents as part of our commitment to continuous improvement and as a learning organisation.
“We are preparing a formal response for the Coroner setting out actions taken in relation to the issues raised. In the meantime, we would like to extend our deepest condolences to the family in this tragic case.”
The trust has until March 27 to respond to the report, containing details of action taken or proposed to be taken as a result of the death.
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