Mental health trust criticised for not treating man prior to his death
PUBLISHED: 06:58 02 March 2020 | UPDATED: 08:12 02 March 2020
Archant Norfolk 2016
The region’s mental health service has been told to make improvements after failing to offer a Norwich man treatment in the run up to his death.
Yvonne Blake, area coroner for Norfolk, called on Norfolk and Suffolk Foundation Trust (NSFT) to take action in an report following the inquest into the death of Peter Frosdick.
Mr Frosdick, 48, was found dead at his home on Silver Street on June 1, 2019.
An inquest in November heard that Mr Frosdick had been found hanged, and while he had taken his own life, was unable to form the necessary intent due to his state of mind.
Ms Blake said Mr Frosdick chronically abused alcohol and had developed cirrhosis of the liver.
The inquest heard he had been advised to stop drinking and became convinced he was going to die of liver failure.
He was referred to a number of NSFT teams, none of which accepted him for treatment as it was felt his problem was alcohol misuse.
In her letter she said she was concerned no-one appeared to look at Mr Frosdick's mental health except to note he was alcohol dependant.
Ms Blake wrote: "His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not take on.
"When seen by the crisis home resolution treatment team, home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to wellbeing services should have been made but wasn't."
She added concerns the teams were unaware of each other's referral criteria and displayed "little or no professional curiosity" despite information from Mr Frosdick's GP saying his condition was worsening and he had been abstinent from alcohol.
Dr Dan Dalton, NSFT chief medical officer, apologised and expressed the trusts condolences to friends and family for his loss.
Dr Dalton said: "Following Mr Frosdick's death, we took immediate steps to improve assessments and records access, and checklists to ensure that referrals are not missed.
"We also arranged senior clinical mentoring and delivered extra training, including on the many elements of risk, particularly focusing on substance and alcohol misuse.
"We've asked services to work closely together to make sure nobody falls between the gaps, and our Wellbeing service has run training with community and acute hospital teams so we work more efficiently together."