A coroner has criticised a "culture of bullying and harassment" at a mental health unit and an attitude among staff that suicide was "inevitable", following the death of UEA student who took his own life.
Jacqueline Lake, the senior coroner for Norfolk, made the remarks in a scathing report after the inquest into the death of 21-year-old Theo Brennan-Hulme, whose body was found in the bedroom of his flat on the university campus.
He had been receiving care from the Norfolk and Suffolk NHS Foundation Trust's crisis resolution home treatment team.
In a report published this week, Mrs Lake said she had heard evidence at Mr Brennan-Hulme's inquest that there was a "loss of compassion" at the team, and a "view that some suicides are 'inevitable'".
She said work had since been undertaken to improve the culture at the team, but that there was "still a distance to go".
She added that it was "of concern that this culture remains three years following Theo's death".
Dan Dalton, chief medical officer at NSFT said Mr Brennan-Hulme's death had been a "tragedy" adding: "We know that the support given to Theo could and should have been better."
He said that changes had already been made to prevent something similar happening again.
Mr Brennan-Hulme's inquest, earlier this month, heard how the popular student, who lived with Asperger's Syndrome, had taken his own life in March 2019, having previously sought the help of the Trust to deal with low mood and depression.
Mrs Lake concluded his death was suicide. This week she published a 'prevention of future deaths' report - a document which is issued when coroners have heard evidence that further avoidable deaths could occur if no action is taken.
In it, she highlighted a series of shortcomings in the Trust's crisis resolution home treatment team.
She raised concerns around how the team had assessed Mr Brennan-Hulme's individual needs, but also about an overarching culture at the unit.
She wrote: "Evidence was heard of a historic culture of bullying and harassment within the Crisis Resolution Home Treatment Team which has led to a loss of compassion in some instances with the view that some suicides are 'inevitable' and some reluctance to recognise when cases should be referred to the Team.
"Work has been undertaken by the Trust to improve such cultural attitudes. However, it was recognised in evidence that there is 'still a distance to go' and areas where the culture needs to change. It is of concern that this culture remains three years following Theo’s death."
Dan Dalton, chief medical officer at NSFT said: "Theo's death was a tragedy and I'm sorry for his family's loss. We know that the support given to Theo could and should have been better.
"Our internal investigation highlighted missed opportunities to help Theo.
"Changes have already been made to prevent this happening again, including improving communication with families and carers, improving the confidence of staff in assessing autistic people and regularly reviewing the accessibility of our crisis services."
If you need help and support, call Norfolk and Suffolk Foundation Trust’s First Response helpline 0808 196 3494 or the Samaritans on 116 123. Both services are available 24 hours 7 days a week. You can also download the Stay Alive app on Apple & Android
Theo's story
The 21-year-old, from Stoke-on-Trent, was a promising first year English Literature and Creative Writing student who started at the UEA in September 2018.
He lived with Asperger’s Syndrome and had a history of deliberate self-harm and shortly after arriving at university he referred himself to the wellbeing team with a low mood and depression.
The following day he went to the Norfolk and Norwich University Hospital, expressing suicidal thoughts.
Contact was made with his mother who came to be with him. He decided to continue at university and was referred to the Youth Mental Health Team. He was discharged from the service without being seen or spoken to.
In January 2019, after he had thoughts of suicide having turned to alcohol and drugs, an appointment with the Wellbeing Service was arranged, but cancelled due to staff sickness and rearranged for March 6.
On February 28, Mr Brennan-Hulme sought help from the university GP service and was referred as an emergency to the community Mental Health Service.
The referral time for an emergency is four hours. Mr Brennan-Hulme was seen after eight hours due to service demands. He was assessed at Hellesdon Hospital and expressed concerns about his future accommodation, relationships and university workload.
The assessment took, at most, 41 minutes.
In her report, Mrs Lake said reasonable adjustments were not made to take into account his diagnosis of Asperger’s Syndrome, contact was not made with his family and he was not referred to the mental health home treatment team.
Mr Brennan-Hulme did not attend the Wellbeing Service appointment on March 6. This was not followed up by the service. His body was found in his flat on March 12.
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