New mental health protocols put in place after Derbyshire man tragically took his own life

The inquest took place at Chesterfield Coroner's Court.
The inquest took place at Chesterfield Coroner's Court.

A much-loved man who suffered with mental health problems took his own life, a coroner has ruled.

John Howard Hall, 63, formerly of Derby Road, Swanwick, ran into the path of a car transporter on the A38 between Ripley and Alfreton, near Swanwick, on July 27 last year and he died at the scene.

During the inquest at Chesterfield Coroner’s Court on Friday, questions were asked about the way in which Mr Hall was referred to mental health services at Derbyshire NHS Foundation Trust and how quickly information was acted upon.

Summing up, assistant coroner for Derbyshire, Peter Nieto, said: “John Howard Hall had experienced anxiety and depression for much of his adult life and at times he had expressed suicidal thoughts.

“He had received medication and talking therapies via his GP Practice and mental health services.

“Two days before his death he was referred to mental health crisis services but for a variety of reasons he was not seen face-to-face by that service before his death although he was engaging with services and had agreed to an appointment which had been arranged for later on July 27 2016.”

At the hearing Mr Nieto asked Mr Hall’s cognitive behavioural therapist if she could have referred Mr Hall to mental health services. She said that her understanding was that the ‘most effective way’ to get help was to go via a GP.

Questions were also asked about the level of information included in the referral to mental health teams by Dr Simon Francis, of Ivy Grove Surgery. Although it was said the referral was ‘not a good example’, it was also added that it would be difficult to say in hindsight whether this would have made any difference to the speed in which the crisis team met with Mr Hall.

Mr Hall, a former teacher, had not been seen face-to-face by mental health teams at Derbyshire NHS Foundation Trust after being referred two days before his death by Dr Francis on July 25.

It was explained that Mr Hall agreed to a face-to-face appointment for July 26 - but this got delayed and then re-arranged for July 27. He took his own life that morning.

Derbyshire Healthcare NHS Foundation Trust has since made some changes regarding referrals.

Mr Nieto ruled Mr Hall’s act on July 27 to be deliberate after a note was found at his home by his wife suggesting his intention to take his own life.

With regards to the changes made to referrals, a spokesperson for Derbyshire NHS Foundation Trust said: “We have clarified processes for our psychological therapies team to make referrals direct to our crisis team when they have serious concerns about an individual’s mental health.”

Mr Nieto recorded Mr Hall’s death as suicide.