Man assessed 3 times before suicide leap Coroner criticises medics for failure to spot risk
AGRANDFATHER took his own life just two hours after mental health workers decided not to admit him as an inpatient.
Marlon Demaine was assessed three times by different mental teams in the 36 hours before his suicide at his Chemseley Wood home.
An inquest at Birmingham’s Coroner’s Court heard how the 50-year-old had told his son James Lyons in “graphic detail” of his intensive suicidal thoughts in the early hours of June 28.
The family told Coroner Emma Brown that they asked for Mr Demaine to be admitted to hospital as they feared for his deteriorating mental health.
But despite three assessments in 36 hours, he later jumped from his fourth floor window on June 29.
He died two days later at University Hospital in Coventry from multiple injuries.
The inquest heard how in the early hours of June 28 Mr Demaine, who suffered with bipolar and schizophrenia, had stood on the window ledge in his flat but was talked down by his son.
He was taken to Heartlands Hospital where he was assessed in A&E by nurse Sanya Dixon-Graham.
But after telling her he was “no longer having suicidal thoughts” he was discharged with a referral to a community psychiatric visit, due to take place later that day.
When no contact was made, Mr Demaine’s ex-partner, Jessica Reinold, visited the Newington Centre in Marston Green to ask that he be admitted as an inpatient.
Mr Demaine was then assessed by nurse Simon Wills, who told the inquest he recalled that he had a fluctuating mood and had become more depressed over recent weeks after a relationship break-up.
Mr Wills recalled that Mr Demaine had claimed: “I’m living a lie. I’ve never loved anyone.”
But again Mr Demaine was sent home, with a visit by a Home Treatment Team scheduled for the following day.
Mr Wills told the inquest : “I’ve thought about it every day since and knowing what happened now, if I could see the future, it would have been different.”
But he said he stood by his decision to send Mr Demaine home as he claimed that he was not presenting any signs that would “warrant an admission”.
The Coroner told Mr Wills she “was troubled” he did consult for a further psychiatric assessment when just hours earlier Mr Demaine had to be talked down from a window ledge.
The next day the Home Treatment Team visited Mr Demaine, but again decided not to admit him. Two hours later he jumped from the window of his flat.
Dr Pramodh Samuel, who was part of the home treatment team, admitted he had not questioned Mr Demaine about the incident just 36 hours earlier where he had stood on the window ledge.
He said: “He didn’t say much. He was in a low mood. He denied any thoughts of suicide or self harm. I didn’t ask him [about the ledge incident]. He wasn’t in a state to explain, he was confused.”
Birmingham and Solihull Mental Health Trust launched an investigation following Marlon’s death, which found his family’s concerned should have been more heavily weighted. A Root Cause Analysis (RCA) report also found a member of his family should have been invited to attend a review appointment on June 12.
Birmingham Coroner Ms Brown said she was concerned the Home Assessment Team had not discussed Mr Demaine climbing onto the ledge.
She said: “One does not see more extreme suicidal behaviour than that. It was known that he would mask his illness, and those that knew him best thought that this is what he was doing. I cannot understand why this incident would not have been discussed when it was important to understand why Marlon had done this.”
Recording a narrative conclusion, Ms Brown said: “Marlon died as a result of suicide, where the risk of suicide had not been correctly assessed and managed by mental health services.”
Following the inquest Ms Reinold said: “The mental health services didn’t take proper care of Marlon, and didn’t listen to us when we told them that he was at serious risk.
“We were very pleased with the RCA report, which we thought was very fair and honest.
“If they had listened and taken us seriously then things would have been different.”