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Thomas and Katherine Kemp of Ipswich had sought help after he threatened to kill himself. Thomas and Katherine Kemp were turned away by the mental health crisis team at Ipswich hospital. Photograph: Chris Radburn/PA
Katherine Kemp, 31, had dialled 999 after her husband, Thomas, 32, had threatened to kill himself in the early hours of 6 August last year. Police arrived at their Ipswich flat while she was still on the phone to the ambulance service and found the couple to be calm.
Officers gave them a lift to Ipswich hospital but the couple were turned away by the mental health crisis team, who mistakenly believed the episode concerned Thomas Kemp’s body dysmorphia, the hearing in Ipswich was told.
He had previously been assessed as suffering from anxiety, body dysmorphic ideas and paranoid delusions and had been due to meet with the psychiatric liaison team later that morning.
The Suffolk area coroner, Jacqueline Devonish, said the failure to consider alternatives to discharge from hospital was a “missed opportunity to have done something effective to prevent these deaths”.
Recording narrative conclusions, she said Kemp stabbed his wife to death during a psychotic episode when she tried to prevent him from harming himself.
The coroner said the deaths were contributed to by Thomas Kemp’s “non-compliance with prescribed medication” and the “failure of the crisis response team to see [Katherine Kemp] and her husband and undertake an assessment”.
Devonish added: “Thomas loved Katherine and wouldn’t have knowingly hurt her.”
Mandy Mckenzie, an A&E receptionist, previously told the hearing that when the Kemps arrived at the department Katherine Kemp had said: “Please can you help, he has knives and is going to harm himself.”
“Mrs Kemp was very distressed and tearful and kept asking for help,” she said. “Mr Kemp made no eye contact and kept looking at the desk. Mrs Kemp kept holding on to his arm.”
Maria Tabar, a triage nurse, said she had assessed Thomas Kemp as high risk and informed the crisis team. She said during her evidence that the crisis team had told her the episode was related to his anxiety relating to his penis, saying: “You know the problem? Suicidal thoughts are not the problem, it was his manhood.”
Devonish said: “Her evidence was they were just laughing about Thomas. She was surprised and couldn’t understand.”
The coroner said she found Tabar to be a “credible, hard-working and sympathetic professional”.
In a statement read by their barrister, Jonathan Metzer, after the conclusions were read out, the family of Thomas Kemp said: “Both Thomas and Katherine reached out for help and they were discharged.”
They said the pair were “failed”, adding: “We don’t want to see the pain our family are experiencing repeated.”
Diane Hull, the chief nurse of Norfolk and Suffolk NHS foundation trust, said after the hearing that the trust had commissioned a review [see below]and identified areas for improvement, including team working and communications.
“There is an absolute need to learn what went wrong and why, so that services can be improved and, most importantly, prevent another family suffering what Mr and Mrs Kemp’s families have been through,” she said.
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Learning Lessons Bulletin — (NHS England Improvement, Niche Health and Social Care Consulting)
At the time of the incident Mr Q had presented to an A&E department in crisis. He had no history of treatment by secondary mental health services. 12 months earlier he had been referred to mental health services by his GP after a crisis in which he threatened to kill himself. He was not accepted for secondary mental health care at that time, but advice on medication and management was provided to his GP.
He presented at A&E four weeks before the incident with insomnia and anxiety but declined an assessment by the mental health liaison service. In the four weeks before the incident there were six contacts with crisis services; two face to face contacts and four telephone contacts.
On the night of the incident he and his wife had been seen at A&E, the referral to the mental health crisis team had been refused, and they were advised to return home to await contact from the psychiatric liaison service. The homicide/suicide occurred early in the morning after they returned to their flat.
Key Findings – Risk assessment and managementMr Q’s risk assessment identified the following concerns:
- Risk of suicide as a result of his belief that he is being targeted by his work colleagues and in
reaction to his ideas of reference.
- Risk of deterioration of his mental state if he refused to take medication, which is very likely as
a result of his lack of insight.
- Risk of violently reacting to his delusions.
[Medication is, as always, ignored as the biggest risk factor. Taking the medication intermittently (“non-compliance”) shows that it was probably causing him problems. The psychosis was probably a medication side-effect possibly related to withdrawal. The facts presented do not address this.]