Paragraph seven reads: "He asked the HTT to admit him to hospital the week before he died but was instead given more anti-depressants and the sedative diazepam."
Trust admits to suicide failings8:57am Wednesday 28th January 2009
By Hannah Crown »
ENFIELD’S mental health trust has admitted failings in its dealings with a man who killed himself after a nervous breakdown.
David Tetlow, from Enfield Lock, strangled himself with a bandage on September 7, 2007, aged 49, after caring for his severely autistic son became too much.
His son Justin, 14, was born at just 26 weeks, sleeps little, and cannot feed, clothe or go to the toilet by himself.
A report by Barnet and Enfield Mental Health Trust, whose Home Treatment Team (HTT) cared daily for Mr Tetlow, found that the team failed to follow its guidelines for setting up a care plan or risk assessment.
It said case notes were sometimes not detailed enough, some staff lacked supervision, and one member of the team “did not have sufficient knowledge and skills” to assess Mr Tetlow’s needs.
Mr Tetlow saw a psychiatrist at Chase Farm Hospital, Enfield, on August 23 after taking an overdose.
He asked the HTT to admit him to hospital the week before he died but was instead given more anti-depressants and the sedative diazepam.
At Mr Tetlow’s inquest in December, Coroner Andrew Walter ruled in a narrative verdict: “An opportunity was lost to speak to members of Mr Tetlow’s family in his absence.
“They may have revealed the true extent of Mr Tetlow’s depressive illness and his desire to go to hospital during the two days prior to his death.”
Mr Tetlow’s wife, Tracy, 41, said: “I got justice for David that day. I have never been angry with David because I know he was ill and if he had been in his right mind he would never have done it.
“[The HTT] knew that with depression one of the symptoms is to cover it up. He promised that if he ever felt like that again he would ask for help and he did and they failed him.”
Despite a social worker assessing the couple as being in urgent need of regular respite in 2006, no plan was put in place until after Mr Tetlow died.
Mrs Tetlow has now got 55 days’ respite a year.
She said: “The root of it all was the lack of care. It absolutely stinks and I think social services know that it stinks because they said they were making extra funding available for it.”
The council also conducted a review after the case which found that senior children’s services managers should review decision making and policy regarding the allocation of resources.
The council will spend £1.2million on care packages in both 2009-10 and 2010-11.
In 2007-8 853 nights’ respite were provided for 61 children, while in 2009-10 there will be 1,584 nights’ respite.
A spokesman for the mental health trust said: “As our consultant psychiatrist stated at the inquest, we now take the opportunity, where appropriate, to talk with the relatives without the patient being present to get a better insight into their circumstances.
“This is a strengthening of our partnership with carers and families, and one of the changes we have made due to our review of this tragic incident.”