Suicide Celexa 30/05/2011 England Suicidal Son of Marquess Kills Self Shortly After A/D was Added to his Mood Stabilizers
Suicide Celexa 2011-05-30 England Suicidal Son of Marquess Kills Self Shortly After A/D was Added to his Mood Stabilizers

Paragraph 60 reads:  "The following day, Lord Milo was seen by Dr Emezie. In his assessment, Emezie too noted that Lord Milo had continued to experience thoughts of 'throwing himself off a building’, and that he had been having these thoughts 'every day for the past two and a half to three weeks, which are increasing in intensity’. He further noted that Lord Milo had not been taking Olanzapine immediately before his breakdown, and put him back on the medication. He also prescribed an antidepressant, Citalopram [Celexa].

Should more have been done to save Lord Milo Douglas?

When Lord Milo Douglas, the bipolar son of the Marquess of Queensberry, killed himself, the health authorities were well aware of his suicidal feelings. His family want to know how he slipped through the net

Lord Milo Douglas Photo: Courtesy of Alexa Queensberry

By Mick Brown 9:00AM BST 30 May 2011

On July 21 2009, at about 6.20am, police were called to the Hallfield Estate in Bayswater, west London, where the body of a young man had been found lying in shrubbery in front of a block of flats, Reading Tower.

Exploring the flats, police concluded that the man had jumped to his death from an open fifth-floor walkway. Lord Milo Douglas, the 34-year-old son of the Marquess of Queensberry, had taken his own life less than a mile from his home, and close to the primary school where, according to his mother, he had been so happy as a child.

By the account of those who knew him, Lord Milo was a sweet and kind young man, but he was also a troubled one. For the previous 10 years he had struggled with bipolar affective disorder – what used to be called manic depression, a condition marked by oscillations between deeply depressive and manic behaviour. In its varying forms, it affects an estimated one in 100 of the British population.

A week before his death, Lord Milo had presented himself at his GP’s surgery announcing that he had been experiencing suicidal thoughts, and expressing a desire to be taken into hospital.

Instead, in line with the Government’s declared policy of home treatment for the mentally ill, Lord Milo came under the care of what is known as a crisis resolution team (CRT), whose function is, wherever possible, to avoid hospitalising patients and to manage them safely in the community.

Two days after coming under the care of the CRT, Lord Milo told the psychiatrist who had been assigned his case that he had thoughts of throwing himself off a high building. Five days later he did.

Mental illness is the one illness where people often need to be, in the truest sense, protected from themselves. According to the most recent figures published by the Department of Health’s National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 4,404 people in England and Wales committed suicide in 2007. Of those, 1,190 were under psychiatric care.

It took more than a year for the inquest into Lord Milo’s death to take place. In that time, concerns about his treatment grew among his family. In a letter to Dr Paul Knapman, the coroner for Westminster, Lord Queensberry spoke of the family’s belief that the death of his son – 'poor, gentle, sweet, careful and conscientious Milo’ – was the consequence of a series of 'tragic missed opportunities’ resulting from failings on the part of the health authorities.

That, however, was not the conclusion reached by Dr Knapman. At the inquest in March, he recorded that Milo Douglas had taken his own life while the balance of his mind was disturbed. The treatment by the CRT, he stated, while 'not perfect’, was none the less 'satisfactory and reasonable’.

But the inquest into the death of Lord Milo raises serious and disturbing questions about the policy of 'care in the community’ that the verdict does not altogether answer.

Milo Douglas was a scion of one of Britain’s oldest, and most colourful, landed families. The Douglases can trace their family tree to the eighth century. In the mid-19th century, the 9th Marquess of Queensberry, John Douglas, introduced the code of rules on which modern boxing is based, the Queensberry Rules.

And it was the relationship of his third son, Lord Alfred 'Bosie’ Douglas, with Oscar Wilde that led Wilde catastrophically to sue the Marquess for libel, after the Marquess had publicly described Wilde as 'posing somdomite [sic]’, resulting in Wilde’s eventual imprisonment.

Lord Milo was the third child of David, the 12th Marquess, and his second wife, Alexandra Wyndham Sich, known as Alexa. Sholto is the eldest, followed by Kate, Milo, Torquil and their half-sister, Beatrice.

The Queensberry title may suggest upper-class convention and stuffiness, but Lord Milo’s upbringing was anything but. His father was the youngest ever professor – of ceramics – at the Royal College of Art and the family mixed with a wide circle from the worlds of art and fashion. All the children were sent to state primary schools.

By his mother’s account, Lord Milo was a happy child, normal in every way except for chronic dyslexia, which was diagnosed when he was seven.

In 1983, when Lord Milo was eight, his parents separated (they divorced three years later), and the younger children moved to Wiltshire with their mother. After attending a minor public school, Dauntsey’s near Devizes, and post-school travels through south-east Asia, Lord Milo won a place at University College, Dublin, to read English and sociology. It was here that his problems with depression began.

As one friend puts it, it seemed that Lord Milo 'always had a few layers of skin less than most people’; he found it hard to settle and make friends. After one term, he applied to go to another university, Manchester. Again, he found it hard to fit in. 'He did seem awfully sad quite often’, his mother, Lady Queensberry, remembers.

Working doggedly, he gained a 2:1 in English, before returning to London to work for an online antiquarian book dealer. He embarked on a gay love affair with a young Italian. When the relationship fell apart, he was devastated. In 1999, when he was 24, he had his first bipolar manic episode.

'It manifested itself by classic behaviour,’ Lady Queensberry says. 'There were overwhelming religious aspects to his thoughts; he became hectoring about moral issues, bewitched by sequences of numbers; he saw other faces superimposed on those of people he knew. He would invite tramps back home and gave away his possessions and money to people sheltering under Waterloo Bridge.’

When his behaviour became unmanageable he was taken to hospital, where his condition was diagnosed. He was prescribed lithium – the standard mood-stabilising medication for the condition. For the next 10 years, Lord Milo would remain under the monitoring eye of psychiatrists, both private and NHS.

In 2003 he moved to Italy where he taught English, then returned to London in 2006 to start work with a charity. Addressing the inquest, his mother stressed how hard he had worked to understand, and to manage, his condition. He took up swimming and jogging, and kept extensive notes about the effects of certain drugs, and observations on his own condition.

'Cannot prevent stressful events,’ he wrote in one note, 'but can attempt to step back from such an event where your natural reaction might be to wade in deeper and thus subject yourself to the risk of a relapse.’

Another note was borrowed from the American Evangelical preacher Charles Swindoll: 'I am convinced that life is 10 per cent what happens to me and 90 per cent how I react to it. And so it is with you…’

Lithium seemed to bring a measure of stability to Lord Milo’s life, although he would talk with his family of the frustrations of inhabiting a 'grey world’ where the worst of feelings might be neutralised but so were the best of them.

'Until his last few months,’ Lady Queensberry says, 'he responsibly took his medication and led a largely fulfilled, positive life.’

In December 2006 a close friend of his sister Beatrice committed suicide. Lord Milo wrote a letter of sympathy. If somebody has suicidal urges, he noted, 'there is very little one can do to stop them. I talk, of course, as one who has been seriously depressed, but whilst I might have more of an understanding of what leads someone to want to kill themselves, I think the sheer force of will that leads a person to commit suicide springs from a mentality quite distinct and almost unfathomable from that which I’ve ever experienced.’

To properly understand the factors around Lord Milo’s death, it is necessary to understand the huge changes that have taken place in the care of the mentally ill over the past 50 years.

Until the 1960s, hospitalisation was regarded as the primary recourse for the mentally ill, but that policy began to change in the light of three factors: the first was a questioning of the very definition of mental illness, and a movement to liberate patients from the stigma it carried; the second was the development of the first antidepressant and anti-psychotic drugs; the third was cost.

The new theory held that patients could live 'in the community’, being treated at day centres while their symptoms were moderated and controlled by medication. The era of 'care in the community’ had begun.

In 1955 there were 155,000 psychiatric beds in the UK. By 1982 that number was 45,000. According to the most recent NHS statistics, the average daily number of available beds for mental illness in England in 2009-10 was 25,503, of which 21,836 were occupied.

Marjorie Wallace, a former investigative journalist who went on to found the leading mental health charity Sane 25 years ago and is its CEO, was a witness to the wholesale changes that took place in mental health policy through the 1970s and 1980s.

'In one hospital,’ she says, 'I remember being on a ward talking to the patients while the adjacent ward was being knocked down by bulldozers, and the manager saying, “I don't know where all these people will go.” They would put the patients into coaches and drive them to seedy seaside lodgings, and bed and breakfasts. In this way patients disappeared into “the community”. The concept was that people would have a “raft” of services. In some areas, it was very successful and the government went full steam ahead on the results of that. But in others the raft proved to be a rather cheap and leaky vessel.’

The most visible consequences were seen in a series of high-profile cases involving psychiatric patients who had been released into the community. In 1992 Christopher Clunis, a paranoid schizophrenic who had been in and out of mental hospitals, murdered a stranger, Jonathan Zito, on a platform at Finsbury Park Tube station. In the same year, a 27-year-old man, Ben Silcock, suffering from schizophrenia, was mauled by a lion after climbing into a pen at London Zoo.

Under Tony Blair, funding for mental health services dramatically increased. The National Service Framework for Mental Health, published in 1999, outlined a range of measures to promote awareness of mental health and put it on equal footing with other health services. But the fundamental ethos, spelt out in a statement sent to The Daily Telegraph from the Department of Health, remains unchanged: 'The vast majority of people with mental health problems are seen and treated by the NHS in the community. This is better for the patient and, in the long-term, more cost-effective for the NHS.’

In December 2008, after eight years of taking lithium, Lord Milo made the decision to stop his medication. 'He said, “I’m very conscious that I may be making the wrong decision but I’m sick of it,”’ Lady Queensberry remembers.

Within a month, he was developing what his medical records describe as 'mild hypomanic symptoms’, including increased religiosity and poor concentration. His psychiatrist put him back on lithium, adding the antipsychotic drug Olanzapine, which stops delusions and hallucinations.

Around this time Lord Milo gave up his job with the charity. To save money, he gave up his rented flat in north London, and moved in with his father at his house in Paddington, obliging him to transfer from the Kentish Town Community Mental Health Team (CMHT), which had been supervising his treatment, to South Paddington CMHT. The consultant psychiatrist in charge was Dr Stuart Cox. But it was Cox’s senior house officer, Dr Munira Blacking, who took personal charge of Lord Milo’s case.

Blacking’s first assessment was relatively positive – she noted him to be 'stable, with good insight’ – but shortly afterwards, following irregular compliance with his medication, Lord Milo experienced a psychotic episode, believing two people who worked for his father were the devil. An ambulance was called and he was put under the care of the North Westminster crisis resolution team based at St Charles Hospital.

Introduced in the late 1990s, CRTs (or home treatment teams as they are sometimes known) are a key component in the philosophy of 'patient choice’, providing – in the words of the Department of Health Mental Health Policy Implementation Guide 2001 – a 'multi-disciplinary, community-based treatment 24 hours a day, seven days a week’.

In this instance, the CRT was to prove highly effective. Over a period of some two weeks Lord Milo was visited at home each day by a doctor and members of the team, and he made a good recovery. On April 14 his father wrote to the local psychiatric services, thanking them for the consistency and high quality of care that had been shown to his son.

Signed off by the CRT, Lord Milo returned to the care of Dr Blacking. But he told his family that he found her unsympathetic. In May he wrote to Dr Cox expressing his concerns: 'I find that I do not have a good rapport with her.’ He requested a change to another psychiatrist.

After three weeks, he had still not received a reply from Cox (who was, it would transpire, on four weeks’ annual leave). Eventually, Lord Milo received a reply, offering an appointment with another doctor on July 23 – six weeks away. Cox would subsequently tell the inquest that he did not actually see Lord Milo’s letter until after his death. Nor did he see Lord Milo personally in all the time he was under his care. (The team had 130-140 patients, he said at the inquest; the consultant couldn’t see everyone.)

Lord Milo was now spiralling deeper into depression. Without informing any of his doctors, he stopped taking the Olanzapine altogether. In early July he spent six days with his mother in Wiltshire. He told her that his feelings of depression were worse than any he had ever experienced – so bad that he had been seriously contemplating taking his own life.

'I said, “You can’t,”’ Lady Queensberry remembers. '“I know how terrible you feel, but I promise you it will get better; if you killed yourself it would destroy us all.” And he said, “I know, Mum, I know. Don’t worry, I won’t.”’

Lady Queensberry did everything she could to lift his spirits; they took picnics and walks, played music together and visited the cinema. His mood seemed to improve. He told his mother that he was thinking of going back to live in Italy, where he had been really happy.

By chance, Lady Queensberry was leaving for Italy that weekend for her brother's 60th birthday celebrations. Lord Milo had been invited. But on the afternoon of July 12 he returned to London to keep an appointment with his GP. 'Promise me you will tell them everything you’ve told me and I know they will help you,’ Lady Queensberry urged. 'I was worried about him. But if I’d had any inkling that he was getting closer and closer to having to kill himself, of course I would never have gone.’

On the morning of July 14, Lord Milo visited his doctor’s surgery where he was seen by a nurse practitioner, Louise Farmery. It was the first time Farmery had seen him, and she was immediately concerned. She told the inquest that Lord Milo spoke of feeling suicidal, and when she asked if he had any plans for suicide he replied that he could jump off Beachy Head. His manner, Farmery said, was 'very clear, very lucid, very calm’. Alarmed, Farmery suggested that he should be referred to the CRT for proper psychiatric assessment. She also suggested to Lord Milo that he might wish to be hospitalised. 'He was very keen for that,’ she said.

Lord Milo was referred back to Dr Blacking, who arranged for him to be seen by the North Westminster CRT. The referral letter that Blacking faxed to the CRT noted – twice – that Lord Milo wanted to see a psychiatrist 'urgently, as he wants to come into hospital as he feels suicidal’. But despite this clear indication of Lord Milo’s own concerns for his wellbeing, it was not acted upon. It was the first in a train of missed opportunities that might have saved Lord Milo’s life.

Giving evidence at the inquest, Dr Cox stated that CRTs operated under a 'duty of care’ to the patient to look at 'the least restrictive option’ in terms of treatment. He acknowledged that this 'partly saved the NHS money’. But he denied that there were any specific targets to keep patients out of hospital.

The North Westminster CRT to which Lord Milo was referred was made up of a non-consultant-grade locum psychiatrist, Dr Anthony Emezie (the same doctor who had supervised Lord Milo’s treatment under the CRT in March), nine community psychiatric nurses (CPNs) and four support workers – unqualified staff who would usually have some experience working in the mental health service in a position such as health care assistant. The team was under the charge of a consultant psychiatrist, Dr Philip Joseph.

In an earlier age, the decision on whether to hospitalise a patient would have lain with the doctors running the psychiatric institutions. But according to Dr Mark Salter, a psychiatrist in charge of a CMHT in east London that works closely with a local CRT, under present policy it is the psychiatrists in charge of the CRTs who have become the 'gatekeepers’.

'Doctors like to be seen to be good at their jobs,’ Salter says. 'And in this new culture, the idea grows that if you’re admitting a person into hospital it’s a failure in some way.’

Salter prepared an independent report on the treatment of Lord Milo at the request of solicitors acting on behalf of the Queensberry family. He is not able to comment directly on the case, but as an experienced and respected practitioner in the field he is well qualified to describe what he believes are some of the inherent failings in the system.

Putting the onus on CRTs to make the decision about whether to hospitalise a patient creates acute problems, he believes. 'Just as across the health service as a whole, a lot of the work that used to be done by doctors is now done by nurses, so in community psychiatric care a lot of the work that used to be done by nurses is done by less-qualified support workers. Quite often you will find that people who are not that experienced at risk assessment – listening to patients talking about hearing voices, or about suicidal or homicidal ideas, things that an experienced psychiatrist or psychiatric nurse would recognise as the warning signs – you’ll find those people are being put into the front line.’

Rota systems compound the problem, he believes. Rather than being seen on a daily basis by the same psychiatrist or fully qualified professional, who could monitor the most minute changes in a patient’s condition, they may be seen by a revolving carousel of psychiatrists, CPNs and support workers, 'all working on a series of implicit incentives to keep patients out of hospital at all costs, because “home care is best”.’

Over the next seven days Lord Milo would be seen once by Dr Emezie, on three occasions by different CPNs, and twice by one support worker. He would not be seen by Dr Joseph.

The first member of the team to visit Lord Milo at his father’s home, on the evening of July 14, was a CPN, Sanna Moilana, who spoke to both Lord Milo and his father. Lord Milo and his father, she wrote in her assessment, 'record that he has never felt this bad in the past when depressed’. She added that he reported 'having active suicidal thoughts with plan to throw himself from high-rise building (has building in mind in London) or from cliff (Beachy Head).’

There was no record in Lord Milo’s previous medical history of his having expressed an intention to commit suicide, or of deliberate self-harm, but his talk of suicide was evidently not seen as a red flag. Lord Milo, Moilana reported, was 'agreeable to work with CRT, feels he will be safe at home…’ and stated that he would contact the CRT 'if unable to cope at home with his thoughts’.

She also noted that Lord Milo was unhappy about discussing his suicidal thoughts in the presence of his father 'and requested CRT would not talk to him about it either’.

The following day, Lord Milo was seen by Dr Emezie. In his assessment, Emezie too noted that Lord Milo had continued to experience thoughts of 'throwing himself off a building’, and that he had been having these thoughts 'every day for the past two and a half to three weeks, which are increasing in intensity’. He further noted that Lord Milo had not been taking Olanzapine immediately before his breakdown, and put him back on the medication. He also prescribed an antidepressant, Citalopram.

Giving evidence at the inquest, Emezie said he was unaware that 24 hours earlier Lord Milo had expressed a desire to be taken into hospital. While it was clear that he was 'clinically depressed,’ Emezie continued, 'as far as I was concerned he was still treatable within a home environment.’

Lord Milo’s case, he went on, was the sort that the CRT deal with 'day in, day out. We deal with people who have self-harmed as a cry for help or as attempted suicide. If I’d strongly thought he was likely to kill himself, I would have admitted him to hospital.’

In its outline of the role and practices of CRTs, the DoH Mental Health Policy Implement­ation Guide specifies that the provision of '24-hour access to senior psychiatrists able to do home visits is vital’. Dr Emezie’s visit to Lord Milo on July 15 would be the last time he would see a psychiatrist. Emezie drew up a plan for members of the CRT to visit Lord Milo every day, but he would not see Lord Milo himself again.

On July 16 Lord Milo was visited by another CPN, not named in the inquest, who described his circumstances as 'well kempt, good environment’ and with 'no evidence of mood disturbance’. The following day, the 17th, he was visited in the presence of his father by a support worker, Mary Quirke. She recorded that he was suffering 'poor sleep and racing thoughts’, but noted an absence of any 'suicidal content’ in his thoughts.

With Lord Milo’s agreement, a further visit was arranged for two days’ time, when he was seen by yet another member of the crisis team, a CPN, Tricia Doble. Doble told the inquest that in the 30 minutes she was with Lord Milo he had talked of having 'strange experiences’, but that he again denied having any suicidal ideation or thoughts of harming himself.

His mother now believes that Lord Milo was simply 'giving up. Four days earlier he’d been talking about killing himself, and nothing had been done,’ she says. 'But how much more can you do than say, “I’ve decided I’m going to kill myself and I’ve decided where”? I’m quite sure that he thought, this is hopeless. An experienced psychiatrist would surely have spotted that.’

Following Doble’s visit, a further review was arranged for the next day with a doctor. But it was not a doctor who visited Lord Milo on July 20, but Mary Quirke, the support worker who had seen him three days earlier. In her notes, Quirke recorded that Lord Milo appeared 'slightly anxious’, and that he had reported hearing 'the voice of the devil’ encouraging him to kill a young relation. He told Quirke that he felt he was being punished for leading a double life – a life 'like Dorian Gray’.

Quirke told the inquest that she had asked Lord Milo if he would act on his threat to harm his relation; he had replied that he wouldn’t.

At the inquest Dr Knapman, the coroner, referred to an observation in the report prepared for the Queensberry family by Mark Salter. The 'bizarre content’ of Lord Milo’s mental state in his conversation with Quirke [his talk of hearing the voice of the devil],’ Salter wrote, was 'very likely to be indicative of a psychotic depressive state, something that of necessity warranted assessment by experienced mental health professionals, preferably one invested with powers to consider compulsory treatment under the Mental Health Act.’

As a support worker, Quirke told the inquest, she was not in a position to make an assessment. Asked by Dr Knapman whether anybody had done a risk assessment of Lord Milo, Quirke replied that she was 'not sure’. She subsequently reported back to her shift coordinator at the CRT that Lord Milo was 'quite unwell’, and reported what he had said about his thoughts of harming someone. But asked by the coroner whether she had perceived there was an immediate risk to Lord Milo’s life, Quirke replied, 'No.’

Unbeknown to anyone, it appears that Lord Milo had already decided on his own destiny the day before Quirke’s visit. Following his death, a letter was found in his computer, dated July 19: regretful and apologetic, it described how his long and difficult struggle with his steadily worsening mood and suicidal ideas had culminated in a final decision to end his life.

On the night of the 20th, after Quirke had left, Lord Milo was joined at home for dinner by his brother Torquil and his sister Beatrice. 'He was very distant, almost in a trance-like state,’ Beatrice remembers. 'He was not really there at all.’

At 10.30pm he went to his room. It would have been in the early hours, as everyone was sleeping, that he left the house and made his way to the Hallfield Estate.

Lord Milo’s death, the inquest was told, was the first suicide on the North Westminster CRT’s watch in seven years. Giving evidence, Dr Philip Joseph attempted to suggest that the presence in Lord Milo’s bloodstream of the sedative Temazepam should add a 'note of caution’ to the assumption that it was suicide at all. There was 'no certainty’ he had decided to take his own life, Joseph said; 'he could have fallen or slipped’ from the balcony at Reading Tower.

Nobody could account for where Lord Milo might have acquired Temazepam. But Dr Knapman gave short shrift to Joseph’s claim. He was well aware, he said, that the Government has a target to reduce suicide rates, and 'there might be lots of reasons for not ruling it as a suicide which would keep everybody happy’. But, he pointed out, the amount of Temazepam found in Lord Milo’s bloodstream – 0.04mg – was far below even the therapeutic level of 0.3mg.

Joseph also said that it was understandable that 'people should look back and say something has gone wrong’. But in the week leading up to Lord Milo’s death, there were no features in his presentation, he said, to make people think he should be hospitalised. Lord Milo, he said, had been 'very happy’ with the crisis team.

At the inquest, Claire Murdoch, the CEO of the Central and North West London NHS Foundation Trust, spoke of her deep regrets over Lord Milo’s death, but said she was satisfied that there had been no 'key omissions’ in terms of his care. 'The steps that were taken were appropriate under the circumstances,’ she said.

In recording his verdict that Lord Milo’s treatment was 'satisfactory and reasonable,’ Dr Knapman seemed to endorse this view.

But Marjorie Wallace of Sane, who has attended scores of such inquests and independent inquiries, believes that the evidence that emerged in Lord Milo’s inquest raises disturbing questions.

'Families so often get sidelined in cases like this,’ she says. 'On one side of the court you have the phalanx of the NHS with its lawyers, PR consultants and professionals, closing ranks to protect each other; and on the other you have families bearing so much grief, being brickwalled in their attempts to find out the truth, and being made to feel they are to blame.

'It was particularly shocking in this case that neither of the consultant psychiatrists in charge of his care over all the months had taken the time to see him, relying instead on a junior psychiatrist, a locum and community teams with changing personnel of varied skill and experience.’ Driven by an incentive to prevent hospitalisation, Wallace adds, CRTs are 'coming to rely more and more on “wing and a prayer” judgments, just hoping that when they leave a patient in distress at home they will not take immediate steps to harm themselves.

'Despite the Government’s rhetoric of patient choice, the evidence from the inquest revealed that mentally ill people have no choice to be admitted to hospital and nowhere to turn when they feel they can no longer live in the community without being at risk. I strongly believe that had Milo’s request to be admitted to hospital been heard, and had he been cared for by one person he trusted, he would be alive today.’

Wallace also believes that Lord Milo’s treatment raises serious questions about the principle of patient confidentiality. 'Had they made the humane and commonsense judgment to override confidentiality, his wider family could have been involved and his and their suffering spared.’

Doctors have a statutory duty of confidence not to disclose medical details without a patient’s consent. But there are exceptions when disclosure may be necessary to prevent serious harm.

In her assessment of Lord Milo’s condition on July 14, the CPN Sanna Moilana had noted his request for the CRT not to talk to his father about his suicidal thoughts. Lady Queensberry believes that his condition warranted the crisis team alerting the family, particularly in light of his telling the support worker on the day before his death of his thoughts of harming a relation. 'He was a danger to himself and technically to other people as well,’ she says. 'If his nearest and dearest had been made aware of what he was revealing, we would have given him round-the-clock support.’

Mark Salter believes there should be more rigorous training in risk assessment for those working in CRTs.

'Patients on the whole whose hallucinations and delusions appear to be taking them into terra incognita are the ones you really want to look out for,’ he says. 'My feeling is that you should rigorously inquire for the presence of or absence of psychotic symptoms and suicidal ideation at every meeting. We need to have people who can spot the terra incognita progression – and ensure the patient is seen by those people. They don’t have to be psychiatrists; they can be nurses or talented support workers. But I don’t think in the pragmatic world of service delivery and funding and resources that we’re delivering at that level yet.’

The Telegraph Magazine submitted a list of detailed questions to both Dr Cox and Dr Joseph about Lord Milo’s treatment. In reply, we received a letter from the head of communications and marketing of the Central and North West London NHS Foundation Trust, Anna Shaw. 'Milo’s death,’ it stated, 'has had a significant impact on all those who work within the CRT and community mental health team and we are committed to supporting his family in providing information as necessary.’ However, owing to the trust’s duty to uphold patient confidentiality, it was not in a position to provide specific details about the care Lord Milo had received.

'The evidence given to the court,’ the letter continued, 'confirmed that Milo’s only request to be admitted to hospital was made to the practice nurse at Milo’s GP practice. This was prior to him coming under the care of the CRT.

'After an assessment by the CRT, it was agreed that Milo would receive support that would enable him to stay living at home. It is important to note that this is the support Milo wanted. He did not ask to be admitted to hospital. If at any point Milo had wanted to come into hospital and had needed to be admitted, he would have been.’

There are a number of triggers in place for CRTs, the letter went on, which, when met, would result in a hospital admission. 'Lord Douglas [sic] was seen six times within the seven days leading up to his death by a variety of experienced healthcare professionals. At no point were the professionals involved concerned that he was a risk to himself or others, or required a hospital admission, nor did he ask for an admission.’

Among the questions to Dr Cox and Dr Joseph, we asked whether it would be customary for a consultant psychiatrist in charge of a CMHT and CRT respectively not personally to see every patient in their care. In response, the trust replied that 'in keeping with national policy and practice’, not all patients under the care of either a CMHT or CRT would be expected to see a consultant during the course of their treatment, 'although a consultant would be aware of all patients through the supervision of their clinical team’.

For Lady Queensberry, no official explanation can answer the abiding question. 'My question is, what else could Milo have done to make himself heard? And that question wasn’t answered. How much more do you have to do to show that you are seeking help desperately and you are very likely to kill yourself?

'For us, the most disquieting aspect of Milo’s case is that the NHS didn’t provide adequate help for a mental health patient in extremis. It can be seen to have responded by sending staff promptly – and daily – on home visits, but the qualifications of these envoys were clearly insufficient for them to appreciate the gravity of his mental state at a time of acute need – thereby rendering their visits pointless. This is not the fault of the team; they did their best. But I do believe this could have been avoided. What I hope to do is germinate some soul-searching among professionals about the flaws in the system, and broadcast the existing dangers to all carers of poor unfortunate patients like Milo. If some future tragedies are averted as a result, we will feel there has been one positive outcome from his death.’

Sane is studying the process of suicide and suicidal feelings to help healthcare professionals and the public to understand the signs that a person is at risk, and to help prevent them taking that irreversible step. Anyone who has attempted suicide and those who have been bereaved are invited to contact Sane’s research team on 020-7422 5537 or email