'Missed opportunities' to spot warning signs before Northamptonshire man's death, report finds

There were “missed opportunities” to spot “warning signs” ahead of the death of a Northamptonshire man who took his own life, a safeguarding report has found.

‘Teo’, who was in his 20s, struggled with mental health issues before his death, the report by the Northamptonshire Safeguarding Adults Board (NSAB) said. His mother said she felt her son was “let down” by services in the last months of his life.

The report said Teo lived with his mother following his parents separating. He began to use cannabis after struggling with their split and was diagnosed with schizophrenia at 16. His mental health worsened following his father’s death in 2019 and he was referred to a psychiatric hospital.

Once he was discharged, his mental health was supervised by the Planned Care and Recovery Team (PCART). Teo was later detained under the Mental Health Act after his mum alerted services of her worries about him. He was readmitted to hospital for care and returned home after three weeks.

An urgent care team visited him after he was discharged but they were told that Teo did not want to engage with them. He was spotted by a train driver standing on the side of a railway line several days later. He denied feeling suicidal to hospital staff after being picked up by British Transport Police and they sent him home without further assessment.

The report claimed there were difficulties with communicating the newfound concern for Teo between partners, with his care coordinator being on leave and his GP receiving the information late due to registration issues. He assured his GP he was ‘okay’ in a welfare call following the incident, but they were not yet aware of what had happened.

His mother then tried to arrange a call with PCART after noticing Teo seemed “different” – she was concerned he was hearing voices as he seemed distracted and was thanking her for “always caring for him”. The team said they would speak to him within 24 to 48 hours. He took his own life later that night.

The report said that it was “not possible to say” if improved risk assessment and communication would have prevented his death. It added: “There was a need to improve the formulation of risk factors associated with suicide. There were missed opportunities to be professionally curious and identify warning signs for suicide.

“Despite the sad outcome, there were many aspects of Teo’s care that did follow clinical guidance and many examples of good practice.”

His mum thought that he had been discharged from hospital too quickly initially, but the report wrote that it appeared that Teo was making a “good recovery”.

It said that details of his care were not always shared properly, and highlighted the “importance of communication between all parties”. It also found that more work needs to be done on “knowing when to involve more specialist services” – it said that Teo being found by the train line was a “pivotal event” and that more questions could have been asked by hospital staff.

The report said: “Risks of suicide cannot be eliminated but they can often be reduced. Learning from Teo’s death needs to be used to reduce the risk of suicide for others.”

David Watts, chair of the Northamptonshire Safeguarding Adults Board (NSAB), said: “This was a very sad case involving the death of a vulnerable young man and our thoughts are with the family and loved ones of Teo.

“Prediction of suicide by people with schizophrenia is known to be complex. Whilst Teo had no history of self-harming or suicidal behaviours he did have multiple associated risk factors.

“Since Teo’s death, agencies involved in his care have already taken steps to address many of the learning points highlighted within this review.”