Jonathan Metzer was instructed on behalf of the mother of a young man, described as highly intelligent, articulate, charming and well read, who was a heavy cannabis user and was diagnosed with cannabis-induced psychosis in 2020.
After two hospital admissions in 2020 and early 2021, he enjoyed a period free of cannabis and psychosis and was discharged by the community team in June 2021. However, in November 2021 he gave up his job and resumed using cannabis, leading to a mental health relapse. His mother sought help from the community mental health team, but he was discharged on 30th November 2021 without being assessed in person and without the team obtaining any information from his mother directly.
In early hours of 2nd December 2021, the deceased was found at home in a bath of water with electrical equipment close by, after having taken an overdose. However, after the deceased was taken by the police to the local Emergency Department, his mother was asked to leave and the deceased was permitted to go out for a cigarette alone, before being seen by the Mental Health Liaison Team. He never returned and died that evening after jumping in front of a train.
Following an Article 2 inquest heard over three days, Assistant Coroner Tony Murphy found that the following matters probably made a more than minimal contribution to the deceased’s death:
- The decision by the community team to discharge him on 30th November 2021.
- The absence of any adequate system at the Emergency Department to record information provided by the police regarding his risk of self-harm.
- The decision by the Emergency Department team not to allow his mother to remain with him in the hospital pending the arrival of the Mental Health Liaison Team.
- Problems surrounding the system for making referrals to the Mental Health Liaison Team.
- The decision of the ED team not to go outside with him when he said he was going out to smoke after his mother was required to leave.
The Coroner also stated that he would make a Preventing Future Deaths Report concerning a lack of clear, workable and accessible guidance to assist Emergency Department staff in supporting vulnerable members of the public and their families.