Coroner criticises NHS trust that failed to respond before young man took own life
GP’S CALL FOR HELP WENT UNHEEDED, SHE SAYS
A YOUNG man took his life after Nottinghamshire’s mental health services failed to react to his doctor’s call for help.
Alexander Lyalushko, who lived in Gedling borough, hanged himself in his home on January 2 after Nottinghamshire Healthcare NHS Foundation Trust failed to act on a request from his GP.
Mr Lyalushko was described as “vulnerable” by Amanda Bewley, assistant coroner for Nottingham and Nottinghamshire, who raised concerns about the trust’s “inadequate review and incident investigation” in a report aimed at preventing future deaths.
He had previously been heavily involved with the service, on account of his diagnoses of autistic spectrum disorder, anxiety, depression and agoraphobia, as well as his history of suicidal thoughts and attempts at taking his life.
Mr Lyalushko’s doctor requested the involvement of the trust’s Gedling Local Mental Health Team on November 22, 2022.
However, Ms Bewley said that, for reasons which have “not been ascertainable”, the request was not acted on.
In Ms Bewley’s prevention of future deaths report, in which coro“if ners make recommendations to avoid similar deaths following an inquest, she said there was a risk of more harm if Nottinghamshire Healthcare NHS Foundation Trust did not improve the way it investigated serious incidents.
“I identified a number of deficiencies with the initial Serious Incident Review which had been undertaken in respect of Mr Lyalushko,” she said.
“It did not identify that a request from Mr Lyalushko’s GP in November 2022 for involvement of its service with Mr Lyalushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalushko’s family to consider whether there were any areas of concern they had which might direct elements of the review.
there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances, I am not reassured that necessary actions to address the serious issue identified – i.e. inadequate initial review and incident investigation following a death – are yet in place.”
After reconsidering the original Serious Incident Review of his death, the trust said it was “insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing)”. The trust said its patient safety investigation lead would carry out a new review by April 26.
Ifti Majid, the trust’s chief executive, said: “On behalf of the trust, I once again offer our sincere condolences and apologies to Alexander’s family and friends.
“We recognise there were missed opportunities and we are considering the coroner’s comments so that we can take steps to improve for the benefit of those who use our services in the future, particularly in regard to the involvement of families.”
Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org.