A decorated war veteran took his own life just hours after telling mental health practitioners he had prepared a way to kill himself.
David John Smith, who served in the British Army for 10 years, had been a student at Edge Hill University's Manchester campus since September 2018 and was in the final stages of qualifying as a paramedic. The 34-year-old had previously been classified as "very high risk" but had refused treatment for fear he would be seen by NHS staff who he worked with, which might have a detrimental impact on his new career.
David, from Lancaster, was found at his home in Tarbet Street by his mum after attending a mental health assessment on March 17 of this year. At the meeting he had revealed a prepared method of suicide, Lancs Live reports.
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During a placement at a GP's surgery in Bolton, David said he had been feeling suicidal to his supervisor. This wasn't passed on to his tutor as it should have been, the inquest at Preston Coroner's Court heard on Wednesday (June 22).
Fay Sherrington, director of student services at Edge Hill University in Ormskirk, said the university hadn't been told of David's suicidal thoughts as expressed to his supervisor. Zoe Williams, a mental health practitioner, saw David on March 5 this year while she worked at Lancashire and South Cumbria NHS Foundation Trust.
Ms Williams told the inquest: "I felt he was a very high risk. By him acting in that manner he was an enormous risk. I felt maybe he should be assessed under the Mental Health Act. He said at the time he wouldn't go through with it because he didn't want to let anyone down but equally he didn't want to do any of the things we suggested because he felt it would impact on his job if they found out, so it was a conundrum for David.
"He said the people he might see could be the people he works with as a paramedic. He thought it would impact on his ability to get his degree. He wouldn't allow us to refer him anywhere else."
The inquest heard that, after David's death, Ms Williams was informed she had been the lead practitioner in his care but hadn't previously been assigned this role. Dr Ian Yates, a clinical psychologist who carried out an investigation following David's death, identified a number of issues within the home treatment team including the role of the lead practitioner, the experience of Mr Hirst and how things could or should have been escalated.
Dr Yates said: "There are a number of things that should have happened. Zoe should have been given an induction, she should have been familiarised with our standard operating procedures on how the team works, she should have been informed she was the lead practitioner for David which she wasn't."
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David's family also had concerns about the assessment carried out at Albert View, Lancashire and South Cumbria NHS Foundation Trust's centre in Lancaster, on the day he died. The inquest heard that David was assessed by an unqualified, but highly experienced, practitioner called David Hirst who did not escalate the case despite David revealing he had prepared a way to kill himself earlier that day.
In a statement Mr Hirst said: "When he left he presented as upbeat and positive. He voiced no intent to harm himself and appeared relaxed."
David's sister, who is a social worker and who attended the inquest with her husband, said: "I just want to convey that I do believe David died by suicide and it's such a significant problem at the moment. It's important the statistics are recognised. If we don't know about it how do things change?"
Returning a conclusion of suicide Area Coroner Richard Taylor highlighted David's previous suicide attempts and the decline in his mental state in the days before his death. He added: "It appears he reassured mental health services on the 17th and suicide is very difficult to predict.
"The system is what it is. David will have been asked if he wants you to be kept informed and people might feel embarrassed or they might not want to bother their family."
You can contact the Samaritans for free 24 hours a day by calling 116 123 every day.
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