Derby coroner’s verdict on the suicide of Derbyshire man by fatal overdose

Posted: 16/01/2014


Family ‘remains concerned’ that his death was preventable

16 January 2014:  The family of a Derbyshire man say they still have concerns about the way mental health services treated him prior to his death last year, after a coroner ruled that he took his own life.

Sean Edson, 51, was found dead on 15 April 2013 at his home in Long Eaton having taken an overdose of medication prescribed to him for the mental illness he had suffered for 30 years. Today (16 January 2014) the Assistant Coroner for Derby, Paul McCandless, concluded the inquest by giving a narrative conclusion, stating that his condition: “finally overcame [Sean] and drove him to take action so extreme that there can be no doubt that he intended to end his own life”.

Mr McCandless seemingly exonerated staff at Derbyshire Healthcare NHS Foundation Trust, stating that Mr Edson was, at the time of his death, “in receipt of a proportionate and focused response by Mental Health professionals.”

Guy Forster, clinical negligence partner at Penningtons Manches acting for Sean Edson’s family, said: “Sadly, for the family, the inquest has produced more questions than answers about whether the mental health services did all they could to give Sean the help he was so desperately seeking. We will now be working closely with members of the family to investigate those concerns as part of potential legal action against the Trust.

“The family is concerned that there were opportunities to prevent Sean’s death which were missed and that, unless these are recognised, so too are opportunities to improve healthcare as a whole.”

Sean Edson’s sister, Julie Roche of Wymondham, Norfolk, remains unconvinced by the inquest findings and has now instructed specialist clinical negligence lawyers at Penningtons Manches solicitors to investigate whether more could have been done to prevent her brother’s death.

Commenting on the coroner’s verdict, Julie Roche, said: “We remain concerned for those vulnerable mental health patients in the care of Derbyshire Healthcare NHS Foundation Trust and would hope that those in authority will be closely monitoring the Erewash Recovery Team and the Radbourne unit.

“The loss of Sean will affect our family for generations. We feel he tried all available means to communicate his deteriorating mental health to those entrusted with his care. He was a loving son, brother and uncle with a strong faith and we are comforted by the knowledge that we will meet again in a better place.”

Background to Mr Edson’s case

Mr Edson had battled mental illness since his early twenties. He had been diagnosed with schizoaffective disorder but had at times managed to control his illness through medication and undergoing therapies such that he had previously been able to work part time and undertake voluntary work with mental health charities. He had served as a director of a local mental health association and was a founder member of mental health charity, Breakthrough (now known as Touchwood).

Over the years Sean had lived a full and active life but his mental health deteriorated towards the end of 2012 when his step-brother was diagnosed with cancer and subsequently died at the beginning of January 2013. This affected Sean badly and he was admitted as an inpatient to the Radbourne Unit at Royal Derby Hospital amid concerns that he was suicidal and possibly ‘stock-piling’ his medication.

He remained as an inpatient at the Radbourne Unit for 4½ weeks but, as health professionals felt that his mental state was stable, Sean was discharged on 4 March 2013.

Initially, Sean was seen by his community psychiatric nurse at regular intervals but, during the week of 11 March 2013, friends reported that Sean had been seen in Long Eaton town centre in a confused and agitated state. The Court also heard evidence from Sean’s family that there was some concern he had tried to harm himself by cutting his wrists. The family were so concerned about their perceived lack of support for Sean that Julie lodged a formal complaint with the Derbyshire Healthcare NHS Foundation requesting a top to bottom review of Sean’s care.

Sean was reviewed by Dr Gupta, a consultant psychiatrist, who responded to Julie’s complaint and confirmed that she had met with Sean and that they were exploring alternative diagnoses. His mental health nurse/care coordinator was to keep in contact with him.

The family remained concerned about Sean who contacted Julie on 11 April in a distressed state saying that the voices in his head were getting worse and that he was going to die. Julie talked to him about his management plan and a shopping list for groceries that he needed. Unknown to the family, Sean also contacted emergency services on two occasions the same day in a plea for help, complaining of “taking the wrong tablets” and feeling as though he was “going unconscious”. He told the 999 operator that he thought he had “been overdosing for years”. 

An ambulance crew attended and consulted with mental health services before a decision was subsequently made for Sean to remain being treated in the community rather than be taken to hospital. The plan was for the care coordinator to see Sean on 19 April, more than a week later.

Tragically, four days later on 15 April 2013, Sean was found dead in his home by a local church minister.


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