A mental health NHS trust has made changes to some procedures following the death of a York man.
Arthur Caesar-Augustus Leighton, 26, took his own life on 20 November 2021.
He was found hanging in the bedroom of the home he shared with his parents on Kirkdale Road, Osbaldwick, an inquest heard.
Police attended and said there were no suspicious circumstances.
Toxicology reports prepared for a post mortem found no alcohol or drugs detected in his blood.
Those tests also showed there was no sertraline in his blood. Sertraline is a drug to treat depression. Its absence suggested it was at least a week since Mr Leighton had taken the medication.
Where to get help
When life is difficult, Samaritans are available – day or night, 365 days a year. You can call them for free on 116 123. And the following organisations also offer advice and help
Mr Leighton, a student, had been treated for depression for a number of years. On 18 November, two days before he died, he was taken to hospital by ambulance after fears he would take his life.
The emergency department at York Hospital referred him to mental health specialists at the Tees, Esk and Wear Valleys NHS Foundation Trust.
After speaking to them, he said he felt better, no longer wanted to harm himself and instead wanted to go home and concentrate on his university course.
After his death, the Tees, Esk and Wear Valleys NHS Foundation Trust carried out a care review of Mr Leighton’s treatment. This was to establish whether the care treatment was to the expected standard; and to establish if there was anything they could do better.
Jeff Whiley from the trust outlined the findings of the report to the inquest.
He said the crisis team had assessed Mr Leighton on the 16 November, but didn’t feed back the outcome to his GP. He was advised of support options, but the details of this weren’t recorded.
Each time he met with members of the team, a risk assessment was conducted in isolation, rather than as part of a timeline considering previous risk assessments. This “may have been a missed opportunity,” Mr Whiley said.
There were also potential safeguarding issues which weren’t explored.
Mr Leighton was a carer, and his needs as a carer hadn’t been assessed since 2019.
As a result of this review, the trust had made some procedural changes. Record keeping had been improved by a new electronic system.
Staff were reminded of the expectations with regard to safeguarding and risk assessments.
New systems had been introduced to check whether patients had had multiple contacts within the trust, and to then make a decision whether their treatment should be discussed at a multi-disciplinary team meeting.
And now each mental health team had a ‘carer’s champion’.
North Yorkshire coroner Jon Heath asked if there was anything in their review that suggested “the outcome would be any different”. Mr Whiley said no.
In his conclusion, Mr Heath found that Mr Leighton had taken his own life, and that on the balance of probabilities he intended to do so.
He concluded that Mr Leighton’s death was suicide.