Coroner calls for a round-the-clock assessment team after mentally-ill man kills himself
A coroner has called for a round-the-clock mental health assessment triage team after there were missed opportunities to treat a mentally-ill man who killed himself.
Chesterfield coroner’s court heard during a four-day inquest this week how Marek Niemczyk, 49, of Hill Cottages, on Grove Place, at Youlgreave, was pronounced dead by an East Midlands Ambulance Service paramedic at about 7pm, on February 18, 2016, shortly after he had been found hanging in his bedroom.
Machine operator Mr Niemczyk had developed a background of mental health illness, according to the inquest, and he had seen his GP, been referred to a mental health team, attended a police station in Derby, been referred to Royal Derby Hospital, attended Bakewell’s Newholme Hospital and had been referred to Chesterfield Royal Hospital.
Dr Robert Hunter, senior coroner for Derbyshire and Derby, said: “At the time of his death he was under the care of mental health services and two days prior to his death he had been assessed by an emergency medicine doctor.
“Although there were a number of missed opportunities to effectively assess and treat Mr Niemczyk earlier, none of these have either caused or contributed to his death.
“Mr Niemczyk had an increased risk of suicide due to the nature of his illness, however there was no imminent risk identified and as such his actions were not reasonably foreseeable.”
Mr Niemczyk’s wife Danuta revealed her husband had become paranoid from April, 2015, and she confirmed he had said he did not want to live anymore and he feared he was being watched.
The couple’s daughter Wiktoria told the hearing how her dad had visited her mum’s work on February 18 and came back and went into his bedroom and her mum returned from work about 6pm to find him hanging.
Wiktoria said: “We went upstairs and tried to open the door but couldn’t and we came back downstairs to get a screwdriver and tried to take the handle off the door and that wouldn’t allow us in and mum suggested going to a neighbour’s house to see if someone would kick the door down.”
A neighbour kicked the door in, according to Wiktoria, before Mrs Niemczyk and her daughter discovered Mr Niemczyk hanging from a wardrobe.
Mrs Niemczyk said her husband had seen a doctor in April and October, of 2015, and he was referred to Newholme Hospital, in Bakewell, but he said he did not want help and he later complained to police in Derby on February 16 someone had been poisoning him but hospital tests revealed nothing in his system.
The inquest heard how Mr Niemczyk had visited and spoken to Pc Blaine Molloy at Peartree police station, Derby, on February 16 who suspected he was suffering from a mental illness after Mr Niemczyk had claimed his wife was trying to poison him and people were out to get him.
The officer checked, according to the inquest, to see if Mr Niemczyk was known to police which he was not and he requested a unit be deployed to contact his wife but one was not available.
Dr Hunter confirmed police had no legal powers to detain Mr Niemczyk because he was in a public place and there was no evidence Mr Niemczyk was showing signs of presenting a risk to himself or others.
However, the inquest heard how the officer searched through the police system and found a contact for a triage team but it was not available and he also called a mental health team in Derbyshire but the line was dead.
Dr Hunter said Pc Molloy also contacted the Derbyshire Mental Health Trust and was put through to a crisis team and he had to be re-routed twice before he was told the crisis team did not deal routinely with police referrals.
The officer was given a further contact number, according to Dr Hunter, and was called back and was informed Mr Niemczyk had been discharged from the Pathfinder mental health service and he was later informed he could not be accepted as a patient.
Eventually, Pc Molloy called an ambulance so Mr Niemczyk could be taken to hospital for an assessment, according to Dr Hunter, and he was later discharged for a follow-up by his GP.
An appointment was made to visit Newholme Hospital on February 17 but Mrs Niemczyk said her husband initially drove away and then met them back at the hospital where he was assessed and taken to Chesterfield Royal Hospital before returning home.
Mrs Niemczyk added that after a restless night her husband visited her at work on February 18 and it was not until she got home at 6.10pm that she and her daughter discovered Mr Niemczyk hanging.
Pathologist Dr McKenna gave the cause of death as hanging and cited mental health issues as a contributory factor.
Police Constable Paul Booker indicated there were no suspicious circumstances.
Derbyshire coroner Dr Hunter concluded Mr Niemczyk took his own life while the balance of his mind was disturbed.
He added that he has written to the Chief Constable of Derbyshire Constabulary, to Derbyshire Mental Health Trust and sent copies to clinician groups to see if an emergency triage team - which determines treatment for patients - can be made available on a 24/7 basis to deal with anyone showing signs of mental illness.
He added he is aware of the pressures psychiatric services are under and that any such triage service would be costly but he highlighted a need for a 24/7 service for the people of Derbyshire.