The way a mental health trust deals with calls about people at risk of harm should be re-examined after a father-of-two from Weston-super-Mare killed himself, a coroner has decided.
Oliver Ford, aged 25, was found hanged in some woods two days after his mother contacted a mental health team with fears about his welfare.
Mr Ford was suffering from paranoid delusions that people were trying to break into his Marconi Close flat in August 2015.
His anxious mum Sarah Ford called Avon and Wiltshire Mental Health Partnership NHS Trust, but she told Avon Coroners’ Court on August 9 she felt her concerns were not taken seriously by nurses.
Two days later, Mr Ford was found dead in Clevedon woods.
Mr Ford’s family questioned whether a telephone assessment was the best way to gauge someone’s mental health, particularly when their history was as complicated as Mr Ford’s, who had a history of drug overdoses.
Senior coroner Maria Voisin has called for Mr Ford’s care to be re-examined to try to prevent similar deaths in future.
She will write to the mental health partnership to find out if the telephone triaging process should also include a risk assessment.
Fiona McGhie, a lawyer from Irwin Mitchell representing the family, said: “Nothing can turn back the clock and return Oliver to his children and family, but the family hope lessons have been learned by the Avon and Wiltshire Mental Health Partnership NHS Trust so no other family has to live with the pain of losing a loved one in these circumstances.”
Ms Voisin said Mr Ford took his own life, but she could not be sure he had intended to do so.
A spokesman for the Avon and Wiltshire Mental Health Partnership NHS trust said: “We offer our sincere condolences to Oliver Ford’s family.
“The trust takes the safety of its service users and staff seriously. A consideration of risk is always at the forefront of our triaging process in order to determine when someone needs to be seen for an assessment of their mental health.
“We now have a new system in place to ensure all relevant information for the triaging process is gathered and documented at the earliest opportunity.”
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