By Charlotte Lillywhite, Local Democracy Reporter
The family of a man who took his own life saw their calls and texts went unanswered by the NHS trust looking after him in the lead up to his death.
Jonathan Hamer, 32, who was diagnosed with bipolar affective disorder, had been under the care of mental health services for many years before he died on April 24, 2024.
Lydia Brown, Senior Coroner for West London, said there were some gaps in the care Mr Hamer received from South West London and St George’s Mental Health NHS Trust due to staff leave and illness in early 2024, although he was still seen in March and April.
In a prevention of future deaths report, Ms Brown said “communication difficulties” meant the community mental health team did not receive “important information” around the time of his death.
Mr Hamer moved into new supported housing in March 2024, shortly before his death. He was unhappy there and only stayed for a short number of days, moving to his mum’s home.
Mr Hamer’s care coordinator went on annual leave, followed by an unplanned period of sick leave, in early 2024. His family and supported housing staff were not told of this, according to the report, and their phone calls and texts were not answered by the community mental health team during this time.
Ms Brown said: “It was unclear at inquest if service users and their support network had been provided with details of any service changes and current up-to-date contact details.
“The community mental health team actively encouraged communication by text message and emails but had no system in place to intervene when the care co-ordinator was not at work and had left no ‘out of office’ message.
“There was no system to return or redirect incoming calls or messages so these remained unread and unanswered.”
Ms Brown found Mr Hamer’s case had also not been given a priority code on the case management system, which meant no expectations were set over when his case would be reviewed or how often he would be contacted.
The coroner warned the trust should take action to prevent future deaths.
A South West London and St George’s Mental Health NHS Trust spokesperson said: “We are sorry that Jonathan’s care was not of the standard that he and his family should have expected from us. We have conducted a thorough investigation and are committed to continuous learning and improvement, including clearer communication with our patients and their families.
“We are continuing to train and develop our staff in recognising signs and symptoms when a patient’s mental health is deteriorating, to prevent relapse in their illness, and to ensure our staff know when and how to refer onwards when needed. Our thoughts are with Jonathan’s family.”
When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit samaritans.org to find your nearest branch.
(Picture: Ron Lach/Pexels)
