Lawyers representing the family of an 18-year-old man who took his own life say the mental health assessment system was “not fit for purpose”, an inquest has heard.
Jade Hutchings took his own life at his home in Haywards Heath, West Sussex, on 21 May, 2020.
Three months before, on 18 February, the teenager attempted to kill himself at his family home and he was taken to A&E at the Princess Royal Hospital in Haywards Heath.
He was first assessed by a mental health nurse, Curtis Ngwenya, and Mr Hutchings said he felt very strongly that if he was discharged from the hospital he would try to kill himself again.
What was said at the inquest?
Giving evidence at the inquest in Horsham on Tuesday, Mr Ngwenya said: “Jade was quite distressed, he said he felt he was a disappointment to his mother, and he was tearful at times.
“It wasn’t obvious to my recollection he had been drinking. He said he had constant migraines, abdominal pain and a right ankle which kept rolling and made him feel quite low.
“He was still saying if he left the department he was still going to attempt to kill himself so I had to come up with a plan so Jade was discharged in a safe manner without putting him at risk to himself or other people.”
Mr Ngwenya therefore decided Mr Hutchings needed to be referred to the Mental Health Act team to assess whether he needed to be detained under the Mental Health Act.
He wrote a report saying he believed Mr Hutchings was a high suicide risk, but was not able to perform a handover as his shift ended before the Mental Health Act assessment could be made.
Two section 12 doctors, Dr Andraws Latif Andraws and Dr Sobhi Yagoub, along with a social worker, then assessed Mr Hutchings again at around 11pm.
They concluded that he was “no longer under the influence of alcohol”, that his presentation had changed since being assessed by Mr Ngwenya, and he was no longer a high suicide risk.
Dr Andraws and Dr Yagoub both believed that the teenager’s main issues were caused by alcohol misuse, and it would be impossible to treat any other potential issues unless he sought help for substance misuse.
They believed that his “risky behaviours” such as attempting suicide would not happen if he stopped drinking alcohol – however the local substance misuse service, Change Grow Live, did not accept referrals and patients needed to refer themselves to their services.
What had Jade’s mum said?
Jade’s mother, Beatrice Hutchings, said the “onus” being on the teenager to self-refer, rather than being referred by his GP or social services, meant opportunities to help him were missed.
The inquest previously heard a statement from her which said: “People built a picture of Jade in their minds based on stereotypes and misunderstandings. He was a quiet boy who wanted a good life.
“He and our family received judgement and inadequate care – as a black family we were treated differently.
“I’m heartbroken by the many missed opportunities there were to help Jade. I’ve lost my trust in people and the way my son was failed by the system is beyond belief.
“I don’t want any other family to be failed the way I was.”
What did the lawyer for the Hutchings family say to Dr Yagoub?
Dr Andraws and Dr Yagoub also both agreed that Mr Hutchings should speak to his GP about his ongoing physical symptoms. They sent a report to his GP suggesting that he should be reviewed if his mental health deteriorated, but again the onus was on Mr Hutchings to make an appointment – and this did not happen.
Michael Walsh, the solicitor representing the Hutchings family, asked Dr Yagoub: “What you’re trying to do is go to the GP to pick up on something and act on it. The simplest way to do that is to ask ‘GP, please do X’ and they can choose to act on it or not.
“What you do instead is you write a very detailed report, send it to the GP, don’t ask the GP to do anything but expect them to read a six-page report and act on it.
“In this case no one acted on it. Your normal practice is not fit for purpose for what you want to do, is it?”
In response Dr Yagoub said: “Sometimes a report is not sent to the GP and we ensure the report is sent when we want the GP to be aware of the situation.
“When we discuss it between ourselves we note why we are referring the person to the GP.
“I don’t doubt the intelligence of the GP, they’re medical practitioners, he will have looked at the whole situation and knows what to do.
“We didn’t specifically ask the GP to see Jade. The report showed he had physical complaints and he had not been to the GP about it, so the report is alerting the GP to it.
“I think the GP should have picked it up.”
The inquest is set to continue next week.
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