A 24-year-old man’s suicide has raised concerns about the lack of communication between different agencies regarding ‘at risk’ people. 

Patrick Soames died on June 21, 2021, having attended various A&E departments nine times following incidents of self-harm in the last month of his life. 

These A&E departments were spread across five different NHS Trusts including: Croydon, Surrey and Sussex, South London and Maudsley, and Surrey and Borders Partnership. 

Patrick also had contact with three police forces in different geographic areas in that final month. 

At an inquest held in Croydon, Coroner Edmund Gritt raised concerns that vital information about the risk he posed to himself was not shared between these different agencies. 

“Five NHS Trusts and three police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him,” Assistant Coroner Gritt said. 

“However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. 

“The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour, which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself.” 

The inquest heard that Patrick lived at home with his parents in South London and was employed.

However, in the final month of his life he experienced a severe emotional deterioration. 

He briefly went missing in Yorkshire prior to his death and had repeatedly self-harmed. 

The inquest was told that his local authority had been made aware by police of the risk that Patrick posed to himself.  

However, that information was only relayed to a sixth NHS trust in an area which Patrick did not live in, therefore none of the NHS trusts that he had contact with were made aware of that vital piece of information. 

Coroner Gritt also heard that there is no national ‘risk flagging’ system for when someone attends A&E having self-harmed. 

Summing up, he said: “There was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history.” 

Coroner Gritts has sent a report detailing his concerns to the Secretary of State for Health and Social Care and the Chief Executive of NHS England. 

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