Health Trust's failings highlighted after death of Tilbury man
By Piers Meyler - Local Democracy Reporter
10th Oct 2024 | Local News
A MENTAL health trust has been criticised for its failure to support a 42-year-old patient from Thurrock who killed himself.
James Agius was found dead at home in Tilbury on December 17, 2022 on a welfare check.
Mr Agius, who had a mental health disorder and severe complex trauma, was undergoing trauma therapy when he took his own life.
A prevention of future deaths report highlighted inconsistencies in North East London NHS Foundation Trust's assessment of Mr Agius.
An earlier inquest heard there had been a difference of opinion from experts as to whether Mr Agius was displaying hypermanic symptoms on February 12 and 13.
Essex coroner Sonia Hayes said evidence was heard that there is new national training for assessing risk for patients with mental health concerns but there was no evidence that the trust has implemented this training.
Mr Agius had a history of previous suicide attempts and self-harming and substance misuse for which he had sought assistance from the mental health team.
Mr Agius appeared to read a phone message on the morning of December 17 2022 but had not responded.
Coroner for Essex Sonia Hayes criticised North East London NHS Foundation Trust for "significant omissions" from his medical record documentation.
Statement from Ms Hayes said: "The medical record documentation for Mr Agius had significant omissions that included an incomplete risk assessment in February 2022 for Mr Agius following his transfer following crisis intervention with the Home Treat Team to avoid an admission to hospital when Mr Agius attempted to take his own life.
"The evidence of assessments of Mr Agius's mental state provided to the inquest indicated a difference of opinion as to whether Mr Agius was displaying hypermanic symptoms on February 12 and 13 2022.
"Evidence was heard that there is new national training for assessing risk for patients with mental health concerns but there was no evidence that the trust has implemented this training."
A spokesperson for NELFT said: "We would like to offer our heartfelt condolences to Mr Agius' family and loved ones at this difficult time.
"We are working on improving the issues identified in the report including implementing a patient-centred risk formulation model. This new approach will help us improve individualised, thorough risk assessments, and the co-design of personalised safety management plans with our patients."
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