Missed warnings in death of man in 20s - report

There were "missed opportunities to identify warning signs" in the death of a man in his 20s who had schizophrenia, a report said.

Northamptonshire Safeguarding Adults Board (NSAB) reviewed the case of "Teo" who took his own life in October 2020.

However, its report said it was not possible to say improved risk assessment and communication would have prevented the death.

"This was a very sad case involving the death of a vulnerable young man," David Watts, chairman of NSAB, said.

The report said Teo lived with his mother after they had moved to the UK in 2010, following his parents' separation.

Teo had struggled with the split and started to use cannabis, with his mental health problems beginning when he was 16 years old, the report said.

He was subsequently diagnosed with schizophrenia and his mental health deteriorated following his father's death in 2019, leading to admission to a psychiatric hospital.

He was later discharged, but after his mother raised concerns he was readmitted.

Teo was discharged again in October 2020, and after a series of incidents he took his own life later that month.

The report said it was his mother's view he had been discharged from hospital too quickly, but the report said it was "in line with clinical guidance".

The report said details of Teo's discharge plan were "needed by all services involved" but they were not received by all of them.

There were also instances where details of his care were not shared between agencies, the report said.

It said communication between all parties was needed "to ensure effective co-ordination of care".

"This is particularly important in the higher risk period following discharge," it said.

"Since Teo's death, agencies involved in his care have already taken steps to address many of the learning points highlighted within this review," Mr Watts said.

He added the board would work with agencies to "ensure our most vulnerable receive greater protection".

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