Review into death of Cambridge man, 23, was 'not credible'

A mental health trust's review into the death of a 23-year-old man was "not credible", an inquest heard.

James Nowshadi, from Cambridge, took his own life while under the care of Cambridgeshire and Peterborough NHS Foundation Trust (CPFT).

A serious incident report by CPFT found no systemic issues.

But Caroline Jones, assistant coroner for Cambridgeshire and Peterborough, raised concern that it had taken matters on "face value".

Mr Nowshadi was found unresponsive at home on 31 March 2020 and later died in hospital in the early hours of 1 April. Ms Jones concluded he died by suicide.

Emily Formby QC, for Mr Nowshadi's family, raised concern the over the "adequacy" of CPFT's review into his death.

Ms Formby said such reports should be a "360-degree assessment to see what happened, what went right, what went wrong".

"What you heard was not that," she said.

Instead, it was an "acceptance of information with any apparent curiosity", she told the inquest.

The inquest heard from the report's co-author that a reference to the method of Mr Nowshadi's suicide was removed after it was "touched up" by the serious incident group, who were not the report's authors.

Ms Jones said she "shared some of the concerns" expressed by Mr Nowshadi's family and that it was "not a credible report in my view".

Mr Nowshadi had a history of depression but was an "exceptional young man" who had had aspirations of becoming a lawyer, the inquest heard.

He was referred to mental health services in early 2020.

Mr Nowshadi did not wish for information about his treatment to be shared with his family.

Ms Jones said she was "satisfied it was appropriate for the trust not to breach James' confidentiality".

But she asked for an urgent review of CPFT's confidentiality policy.

A CPFT spokesman said: "The death of James was a tragedy and we send our condolences to his family and friends.

"We take all incidents very seriously and investigate them all to see what lessons can be learned, what support can be offered to patients, families and staff affected, and how practice can be improved in the future."

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