Jonathan Metzer appeared on behalf of the family of Thomas and Katherine Kemp at a 6 day inquest at the Suffolk Coroner’s Court, in which the Coroner recorded significant criticisms of care provided at Ipswich Hospital.

Thomas and Katherine Kemp were a married couple aged 32 and 31. Thomas suffered from significant anxiety and body dysmorphia, for which he had been in contact with mental health services for almost a year.

In the early hours of 6th August, Thomas attempted to get hold of a large kitchen knife to harm himself, in what his psychiatrist considered was likely to have been a psychotic episode. Katherine prevented him from stabbing himself and a police team was dispatched, which took the couple to the A&E department of Ipswich Hospital.

Katherine informed the A&E receptionist about the incident with the knife, but this information was not passed on to the triage nurse. Nevertheless, the triage nurse graded Thomas to be at high risk of suicide in light of his presentation and referred him for assessment by the out-of-hours crisis response team. Despite this referral, the mental health nurses did not undertake a face to face assessment and discharged Thomas from hospital on the basis that he had an appointment with his psychiatrist scheduled for the following day. The A&E sister did not challenge the decision by the mental health team and the couple returned home the same morning.

Later that morning, the couple were discovered at their home with multiple stab wounds. The Coroner concluded that Thomas had died from self-inflicted knife wounds following a likely psychotic episode and Katherine had died from wounds inflicted by her husband as she attempted to prevent him from self-harming.

At an inquest convened under Article 2, the Coroner recorded a narrative conclusion which included a number of significant criticisms of the care provided at the hospital.

In particular, the Coroner recorded that “[There] was a missed opportunity for the receptionist to share important information with the triage nurse”, “Disappointingly, the crisis response team … decided to turn Thomas away without seeing him or speaking to him, and without any conversation with the reviewing triage nurse”, and “The nurse in charge missed an opportunity to ensure that Thomas was properly assessed by failing to challenge the decision … This was a missed opportunity to refer Thomas back to the crisis response team”.

Jonathan was instructed by Marianne Harrington of Fosters Solicitors.

This case has been covered by the media below.

Alternatively, you can listen to coverage of the inquest on BBC Radio 4’s Six O’Clock News on 17/04/19 here (from 7 mins, 30s).