Gamekeeper took own life days after being told he didn't need hospital bed

Trevor Killington died on May 10, 2021 after his mental health deteriorated during lockdown, with a court hearing he had become "thoroughly bored and frustrated" at not being able to go walking or shooting.

During an inquest into his death, concerns were raised about the treatment he received from mental health services - particularly surrounding a decision not to admit him to hospital.

Of this, area coroner Yvonne Blake said: "It seems to me to fly in the face of logic and of common sense, and was nonsensical."

The inquest, which lasted four days, heard the 72-year-old had been admitted to Hellesdon Hospital twice and on both occasions he and his family had been frustrated by his care and requested his discharge.

But the court heard how disagreements within different parts of the Norfolk and Suffolk NHS Foundation Trust (NSFT) prevented him from being admitted to hospital for a third time.

An initial assessment on Mr Killington had been carried out by his care coordinator and a consultant psychiatrist on May 5, via Zoom, which concluded that he would benefit from a bed.

However, this decision was overruled by trust management, due to it being held remotely against its guidelines to conduct assessments in person.

A second assessment was then carried out on May 7 in person, from which Mr Killington was sent home, with two mental health nurses from NSFT's crisis team judging he would be better off treated in the community.

The inquest heard the decision was made against the recommendations of a consultant psychiatrist, who had raised concerns that Mr Killington's previous community treatment had fallen short.

Questioning why the nurses had overturned the decision, Mrs Blake said: "What gave the nurses the ability to say they knew better than a consultant psychiatrist? That to me seems like an A&E ward sister telling a consultant surgeon that a patient does not need an appendectomy."

Nicky Shaw, from NSFT, said "our nurses are experienced clinical practitioners in their own right", adding that patients can present in different ways from day to day.

Giving a narrative conclusion, Mrs Blake said: "I find that Mr Killington had mental illness in 2020 and 2021 owing to the Covid pandemic.

"He was prescribed numerous anti-depressants, some of which he took once or twice then stopped and others not at all. To start with these were prescribed by his GP with whom he had a long and trusting relationship.

"The mental health crisis team did not discuss his medication with his GP and on one occasion prescribed one that the GP had thought unsuitable.

"I find the reasons given for his non-admission [on May 7] were against the advice of consultant psychiatrists and did not take into account his previous failed treatments with the crisis team."

The inquest heard that Mr Killington had struggled with various forms of medication, often suffering side effects including feelings of aggression.

As a result he was given several types of antidepressants but rejected most.

It also heard that members of the crisis team had come to several disagreements with his wife, resulting in the trust insisting he only be seen on his own and outside of his home.

Mrs Blake added: "I accept that he should have been admitted into hospital on May 7, however, I do not accept that it would necessarily have prevented his death."

She said there was "no guarantee" that while in hospital he would not still have ended up taking his own life.

Mr Killington was due to have a medical review on May 11, but died in his home in Russell Avenue, Norwich, the day before. His medical cause of death was hanging.

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What has the trust said since?

Stuart Richardson, chief executive of NSFT (Image: NSFT)

The NSFT said that since Mr Killington's death, changes have been made to improve the way its teams work together in an effort to avoid similar disagreements.

Stuart Richardson, the trust's chief executive, said: “We would like to offer our sincere condolences to Mr Killington’s family for their tragic loss.

“We carried out an internal investigation following Mr Killington’s death which highlighted some areas for improvement.

"This included considering how multiple teams work together in complex cases and making sure capacity assessments are formally recorded at appropriate times.

"A project has also begun to develop handover documentation which will be used trust-wide to improve the consistency of care which service users receive when moving between teams.

“We will now review the coroner’s findings to see whether there are any further steps we could take to prevent a similar incident from happening in the future.”

Mrs Blake also expressed frustrations that different health organisations continue to use differing computer systems to keep records.

She added: "You have to appreciate my weariness having heard time and time again that people have been judged to be low risk and then gone on to take their own lives."

Despite her concerns, she said she would not be issuing a report to prevent future deaths.