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Inquest concludes death of Leon Evans contributed to by failings of community mental health services

20 July 2018

Taimour Lay

The family of Leon Evans were represented at the inquest by Taimour Lay of the Garden Court Chambers Inquests & Inquiries Team.

On 19 July 2018 Senior Coroner Nadia Persaud at Walthamstow Coroners Court handed down her conclusion following the inquest into the death of Leon Evans. She concluded that his death had been contributed to by failings of mental health services.

Leon, who was from Dagenham and 36 years old at the time of his death, started to exhibit symptoms of depression and psychosis in May 2017 following a bereavement. During the next three months he came into contact with mental health services following acts of self-harm. He was sectioned in July 2017 after one such attempt but was sent home after only three days.

Following Leon’s discharge he came under the care of the local Home Treatment Team and later the Community Recovery Team, both part of North East London NHS Foundation Trust.

The Senior Coroner found between 14 August 2017 and 20 August 2017 Leon was not assessed with sufficient frequency in accordance with the risk of harm he posed to himself and there was a failure to take more proactive steps to engage with him and his family. Leon was only assessed following a further suicide attempt on 20 August 2017.

On 21 August 2017 a community care plan was put in place but was not complied with. Steps were not taken to provide Leon with a sickness certificate for work or to arrange urgent psychological therapy to help him cope with ongoing auditory hallucination. There was no evidence of a full assessment of Leon’s mental state and further no face-to-face contact with Leon prior to 11 September 2017 when he took his own life.

The Senior Coroner concluded that Leon’s death ‘was contributed to by a failure of the mental health services to fully assess his mental state, to fully assess his risk of suicide (by gathering, considering and sharing key clinical information) and to put in place and carry out robust management plans to address the risk.

Leon’s mother, Elaine, and partner, Victoria, said:

Leon was loud and happy-go-lucky; he is sorely missed by his family and friends. The Coroner has concluded, as we had strongly believed all along, that the Trust let Leon down. We tried to get Leon help but feel we were not listened to. If more had been done by mental health services we believe Leon would still be with us today. The Trust has indicated that they have learnt lessons from Leon’s death and we hope as a result another family will not have to go through what we have been through.”

Clair Hilder of Deighton Pierce Glynn Solicitors representing the family, said:

For this model of care in the community to work, it requires clear plans, regular reviews, responsive family liaison and proactive staff. Leon was allowed to fall through the gaps in a mental health service that simply wasn’t functioning to keep a vulnerable man safe”.

The family are represented by Clair Hilder and Christina Juman of Deighton Pierce Glynn and Taimour Lay of Garden Court Chambers.

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