Coroner warns of severe mental health understaffing following a harrowing suicide case

A coroner has written to NHS managers over understaffed mental health teams following an inquest into a young man’s suicide.

Patricia Harding, Senior Coroner for Central and South East Kent, sent a Prevention of Future Deaths report to the Kent and Medway Integrated Care Board and the Kent & Medway NHS & Social Care Partnership Trust regarding the death of Benjamin Hart last October.


Hart, 25, had post-traumatic stress disorder, enduring personality change after a catastrophic experience, emotionally unstable personality disorder borderline type and generalised anxiety disorder. He also likely had Asperger’s syndrome.

Following a suicide attempt in late 2021 he was formally sectioned, and after his release he was allocated a care coordinator from the local community mental health team. But while his care plan envisaged weekly involvement from his care coordinator, they only saw each other on three occasions between May 2022 and his death five months later.

The NHS trust was aware that the relationship between Hart and his care coordinator had broken down, but no replacement was appointed and he had no contact from the community mental health team for five weeks before his death.

He telephoned the crisis team three times in the two days before his death, including complaints of having been abandoned by the mental health team, expressions of hopelessness about his future and indications that he felt suicidal. He was told the community mental health team would contact him, but even though the team and his care coordinator were notified of Ben’s calls the day before his death, no one attempted contact until after he had died.

Kent & Medway NHS Partnership Trust accepted at the inquest that the care provided to Hart fell below the standard he could have expected to receive and there were missed opportunities to treat him.

The Trust had a shortfall of nursing staff in the Dover and Deal area at the time Hart was under the community mental health team – even though 16 nurses were required to run the service, only eight were employed at the time, two of whom were long-term sick. This left six nurses to cover the whole area, requiring them to take on additional duties. As a result, when the relationship between Hart and his care coordinator broke down there was no capacity within the team to provide a replacement.

Harding wrote in her report that ‘although the Trust has regrouped, reorganised and there has been some limited recruitment the shortfall endures; the evidence given at the inquest being that this is a national issue but it is particularly difficult to recruit within this area of Kent’.

The two NHS bodies have until 26th May to respond to the report.

Image: Marcel Strauß


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