Killing ‘could have been stopped’ — (BBC News)

SSRI Ed note: Man given sertraline for workplace anxiety becomes depressed, suicidal, angry. Med switched to venlafaxine, he murders his former girlfiend, hangs himself.

BBC News

18:46 GMT, Friday, 10 October 2008 19:46 UK

SSRI Stories Summary:  In April, 2007 Khalid Peshawan, originally from Iraq, visits his GP complaining of low mood and anxiety stemming from a situation at work.  He suffered an injury and his employer is pressuring him to return.  His GP prescribes Sertraline (Straline/Lustral/Zoloft) 50 mg.   Two weeks later KP reports that the medication is not helping so the GP doubles the dose.   May 24 the dose is doubled again to 200 mg and Diazepam is added.  KP’s mood does not improve but he becomes suicidal and angry.  He states that he is “worried that he might ‘lose control and hurt his close friends’”. Some time in the summer he drinks, almost hits a police cruiser, is verbally abusive and has his driving license revoked. By Oct, KP is not doing well.  He has serious financial problems and he wants to return to work now but his employer refuses to allow him to, because of his medication.  On Oct 1 he sees a Consultant Psychiatrist at the Trust and admits that he has suicidal thoughts.  The psychiatrist decides KP needs to change antidepressants, and the plan is to add venlafaxine and wean KP off the sertraline.  Zopiclone is added and the Diazepam continued.   After this he breaches his Community Order *which he got in 2003 after he stabbed a man in the leg during an altercation at a night club), fails to keep appointments with his care coordinator, and gets a mental health assessment in mid-Oct.  KP continues to be suicidal.  By Oct 15 he has successfully weaned himself off the sertraline and is taking venlafaxine but needs the Diazepam to make him feel better.  On Nov 26 his friend sees him, and he is drinking and taking tablets. When KP leaves, his friend calls police but KP kills his former girlfriend and hangs himself.

The Investigation report considers the following areas for better management of KP’s case:

14.1. Diagnosis, Medication and Treatment

14.2. Post Traumatic Stress Disorder

14.3.Risk Assessment and Forensic Risk History

14.4. The Care Programme Approach, Assessment and Care Planning

14.5. Use of the Mental Health Act (83)

14.6. Cultural Diversity

14.7. Adherence to National and Local Policy and Procedure

14.8. Competence and Experience of the Clinical Team

14.9. Clinical Supervision

14.10 Documentation

14.11. Lone Worker Issues

14.12. Management of Clinical Care and Treatment

14.13. Clinical Governance Processes

Under Diagnosis, Medication and Treatment, pages are devoted to whether KP’s diagnosis was correct.  They also note that:  “Between the period of the 12 April and the 28 June 2007 Mr. X’s anxiety and depression appeared to grow worse”.

They also noted:  “The Independent Investigation Team believes that the GP prescribed medication was appropriate and fell within clinical guidelines.  The change to Mr. X’s medication appears to have been made on reasonable grounds as he did not appear to be responding to Sertraline…The decision to continue with Valium [Diazepam] could be questioned as it was apparent that it made Mr. X drowsy and unable to go about his daily business. “

The report also records that:  “It is not clear how well Mr. X understood the medication that he was prescribed. Nowhere in his clinical records is it recorded that the benefits and possible side effects of his medication were explained to him.”

It was not just KP that does not appear to understand the potential effects of the medication.  Both the Trust and the investigation team noted that KP (Mr. “X”) got worse on sertraline and other drugs.  It is not clear why they assumed that venlafaxine (Effexor) would help where sertraline had made the situation worse, and why they did not even consider the potential connection between the SSRI/SNRI, the suicidality that emerged when KP started these medications, and the tragedy.

To view original article click here

A trust has been set up in memory of Halimah Ahmed

The death of a 19-year-old woman suffocated by her ex-boyfriend could have been stopped, a coroner has ruled.

Khalid Peshawan, 33, killed Halimah Ahmed at his Derby home in November 2007 before hanging himself.

Coroner Dr Robert Hunter said mental health professionals should have properly assessed Mr Peshawan.

It also emerged that in 2005 the former asylum seeker was granted indefinite leave to remain in the UK, despite a stabbing conviction two years earlier.

Halimah remains and has always been a source of inspiration for us

Ashtiaq Ahmed, victim’s father

Derbyshire Mental Health Trust said it would review the coroner’s findings.

Mr Peshawan had told friends life “was not worth living” and he felt suicidal because he could not continue a relationship with the woman he loved.

Mr Peshawan failed to be fully assessed for possible detention under the Mental Health Act on three separate occasions.

It was either because a social worker was unavailable or Mr Peshawan could not be found, the court heard.

Just a few days before Miss Ahmed was killed, community psychiatric nurse Karen Stone assessed Mr Peshawan, an Iraqi Kurd, as a “significant risk to others”.

She said he had talked of harming himself.

Refused asylum

Summing up, Dr Hunter said “on the balance of probabilities”, the events of 26 November could have been avoided had a full assessment of Mr Peshawan been carried out.

Miss Ahmed’s father, Ashtiaq Ahmed, said he hoped the findings would prevent anything similar happening again.

Speaking after the inquest, he said: “Halimah remains and has always been a source of inspiration for us.

“Her vision will be realised through the Halimah Trust.”

Mr Peshawan was refused asylum in 2000.

In 2003 he was convicted of stabbing someone outside a nightclub and given a community service order.

But in 2005 he was granted indefinite leave to remain in the UK, the hearing was told.


To view complete report click here

An Independent Investigation into the Care and Treatment of a person using the services of Derbyshire Mental Health NHS Trust

Undertaken by the Health and Social Care Advisory Service

Ref 2007/13112

January 2010

Excerpts (Complete Report is 148 pages)

4.1. Incident Description and Consequences

The following account has been taken from the transcript of evidence heard at the Inquest into the deaths of Mr. X and Ms. Halimah Ahmed.

On the afternoon of the 26 November 2007 19 year old Ms. Ahmed rang her mother at 3.30 pm to inform her that she was going to visit friends from university. At this point it is assumed that Ms. Ahmed left the family home where she lived, in her car, to pursue the visit she planned to make.

A little later that same afternoon Ms. Ahmed’s mother tried to call her on her mobile telephone and was diverted through to voicemail. When Ms. Ahmed missed the family meal that evening her parents grew increasingly concerned and at around 9.30pm Ms. Ahmed’s father telephoned the police, but declined to report her missing at this stage as he hoped that she would return home. At around 11.30 pm, when she had still failed to return home, Ms. Ahmed’s father telephoned the police again, this time to formally report her missing.

On the 26 November 2007 thirty-three year old Mr. X went to see his GP, on this occasion he was described by both his GP and his friends as being calm and relaxed. Following this appointment Mr. X went to a solicitor’s firm in order to make a will. He was informed that his will would be finalised the following day.

At 4.30pm Mr. X met up with his brother outside of the shop that he (his brother) owned. Mr. X’s brother stated to the Coroner that on this occasion Mr. X appeared to be ‘normal’ in his presentation, although he was a little tired and decided that he was going to go home.

Later on that afternoon at around 5.00 pm Mr. X telephoned a friend saying that he had a ‘problem’. Mr. X went to this friend’s house and was described by him as looking uncomfortable: his eyes were red and he was shaking.  The friend was concerned because Mr. X was drinking and appeared to be swallowing tablets.  Mr. X ran away out of the house and his friend telephoned the police because he was worried about Mr. X’s wellbeing. Mr. X was not seen alive again.

The following day Mr. X’s brother was unable to contact him via his mobile telephone as it appeared to be switched off. Mr. X’s brother went to Mr. X’s home. The front door was not locked and he entered the house. Mr. X was found dead hanging by the neck and a young woman was also found dead on the floor directly next to the body of Mr. X.   Later that same day the young woman was identified as being Ms. Halimah Ahmed.   Dr. Robert Hunter Her Majesty’s Coroner for Derby and South Derbyshire found that Mr. X ‘had taken his own life by ingesting a quantity of Paracetamol and Aspirin and had hung himself…and died as a result of the hanging’ and that Ms. Halimah Ahmed had been unlawfully killed by Mr. X.

At the time of Mr. X’s death he had been in receipt of community-based mental health services from the Derbyshire Mental Health Service NHS Trust. He had received his care and treatment from this organisation for a period of some fifteen weeks. His diagnosis had been determined as depression with symptoms of Post Traumatic Stress Disorder. Mr. X was 33 years old at the time of his death and was member of the Kurdish Iraqi community in Derby.

  1. Chronology of the Events

This Forms Part of the RCA First Stage The chronology of events forms part of the Root Cause Analysis first stage. The purpose of the chronology is to set out the key events that led up to the incident occurring. It also gives a greater understanding of some of the external factors that may have impacted upon the life of Mr. X and on his care and treatment from mental health services.

During the course of this Investigation it was not possible to speak to the friends and family of Mr. X and so it has not been possible to draw up a comprehensive chronology in the context of his life history. Mr. X was only known to Derbyshire Mental Health Services for a period of some fifteen weeks, during this time attempts were made to get to know Mr. X. However Mr. X was often reluctant to talk about himself and the subsequent information held within the clinical record is often incomplete and may not be entirely accurate. The following information has been taken from Mr. X’s clinical records, probation service records and the transcript of the Coroner’s Inquest.

Background Information Mr. X was of Kurdish ethnicity born on the 24 August 1974 in Iraq. It is unclear how many siblings Mr. X had, but it would appear that at the time of his death both of his parents were still living and domiciled in Iraq, and that he had one brother living in the United Kingdom at an address close to Mr. X’s home11.

It would appear that Mr. X’s life in Iraq was turbulent. When talking to his CPN/Care Coordinator at the Trust he described an event in 1983 when he had witnessed people being killed. The history that the CPN/Care Coordinator took gave a very brief account of Mr. X’s childhood, however it would appear that bombings and violence were a day-to-day part of his life as a child and young person. In 1986 Mr. X stated that one of his brothers died at the family home as a result of shrapnel wounds and that he had witnessed this event12

Mr. X left Iraq to live in the United Kingdom, it is not clear exactly when this was, but it was likely to have been sometime in 1999 or early 2000. The clinical records suggest that his decision to leave Iraq was the direct result of an unsuccessful love affair. It is not possible to understand fully Mr. X’s decision to leave his home and family behind from the clinical records alone, and it must be borne in mind that many other factors may have influenced his decision to move to the United Kingdom13.

30 March 2000. Mr. X made a formal application for asylum in the United Kingdom. He was served Form ISI51A, which was a notice to a person liable to removal as an illegal entrant and was given temporary admission to the United Kingdom pending a decision on his asylum claim14.

5 June 2000. Mr. X registered with a Medical Centre so that he could receive primary care health services15.

6 July 2000. Mr. X’s application for asylum was refused, however he was granted exceptional leave to remain in the United Kingdom until 6 July 2004. Mr. X had the right to appeal. There is no trace in the Home Office Records that an appeal was lodged16.

9 September 2003. Mr. X was convicted at Derby Crown Court of stabbing a person in the leg outside of a nightclub. Mr. X was given a Community Punishment Order of 150 hours. The person whom Mr. X stabbed was also Kurdish and known to him and both men had been involved in a previous altercation, when Mr. X had been assaulted. On the occasion Mr. X committed this offence there was evidence brought to bear that he had been provoked. Neither the Courts nor the Probation Services felt Mr. X to be dangerous and no Supervision order was sought. 17.

28 April 2004. The Home Office received an application from the Immigration Advisory Service for indefinite leave to remain in the United Kingdom on behalf of their client Mr. X18.

22 August 2005. Mr. X was granted indefinite leave to remain in the United Kingdom. Mr. X’s former conviction was noted and it was judged not to be sufficient to warrant the refusal of Mr. X’s application. Full security checks were conducted into Mr. X’s background, all of which proved to be negative19.

22 August 2006. The Home Office received an application from Mr. X for naturalisation as a British Citizen20

16 November 2000 – 23 February 2007. Between the 16 November 2000 and the 23 February 2007 Mr. X attended his GP surgery a total of 39 times for the treatment of minor skin conditions and injuries

12 April 2007. On this day Mr. X presented at his GP surgery with ‘low mood and anxiety++’. It was estimated by the GP who saw Mr. X that he had probably been feeling this way for a period of some six months. It appeared that Mr. X’s anxiety at this stage stemmed from an injury he had received at work. Mr. X felt that he could not return to work and he was coming under increasing pressure from his employer to do so. He was worried about paying his mortgage and meeting his financial commitments. He was prescribed Sertraline tablets 50mg once daily.

26 April 2007. Mr. X visited his GP surgery again. It was recorded that he had not noticed much benefit from the Sertraline and that he was still very anxious about returning back to work. The GP decided to increase the Sertraline tablets to 100mg once daily and that Mr. X would need to be seen again in two weeks time. The diagnosis at this stage was depression anxiety.

28 April 2007. Mr. X nearly hit a police vehicle whilst out driving his car. Mr. X appeared to smell of alcohol and he became verbally aggressive when asked to supply a sample of breath which he refused to do. He was arrested and charged with failing to supply a sample of breath24.

10 May 2007. Mr. X was seen at the GP surgery once again. He discussed his low mood with the GP and explained that he felt isolated from his family.

24 May 2007. Mr. X was seen once again at the surgery. The GP who saw Mr. X on this occasion wrote ‘depression + post traumatic stress’. The GP increased Mr. X’s medication to Sertraline 100 mg twice daily. It was also noted that Mr. X was due to see his Occupational Therapy doctor at his place of work the following week26.

28 June 2007. Mr. X was referred to the Derby City Community Mental Health Team by GP 1 at a Medical Centre. The referral letter stated that Mr. X was a 32 year old man with depression and post traumatic stress disorder. The letter outlined Mr. X’s symptoms and sought some psychological intervention from secondary care services. It was noted that Mr. X’s medication comprised Sertraline 200 mg and Diazepam 5 mg27.

3 July 2007. On the 3 July 2007 Mr. X was sent a letter inviting him to make an appointment with the Derby City Community Mental Health Trust.  Between the 12 April and the 3 July 2007 Mr. X was also seen on nine other occasions for minor injuries and pain at his GP surgery.

10 July 2007. Mr. X was written to by mental health services confirming that an appointment had been made for him to see a Community Psychiatric Nurse (CPN) who had been allocated as his Care Coordinator at St. James House on the 16 August 200729.

16 August 2007. Mr. X was seen at St. James House by the CPN. Mr. X’s history was taken and an initial assessment was commenced. It was noted that there was no evidence of paranoia or of persecutory beliefs. It was also noted that Mr. X was very angry and could not control his feelings when talking about his experiences in Iraq, Mr. X acknowledged that he was often angry and was worried that he might ‘lose control and hurt his close friends’. Mr. X explained that he experienced flashbacks of traumatic events and that when this occurred he lost concentration and was vulnerable to accidental injury. Mr. X said that the antidepressant he was taking helped his mood, but that he found it difficult to sleep at times and was often tearful. This initial assessment was recorded on Trust Cognitive Behaviour Therapy Documentation, not on the Trust Care Programme Approach documentation.

29 August 2007. The CPN saw Mr. X at St. James House and continued the assessment process.

5 September 2007. Mr. X did not attend the appointment with the CPN that had been offered to him

Later on the same day the CPN spoke to a member of the Crisis Team who agreed to meet with Mr. X. However Mr. X changed his mind and refused to be seen. The CPN discussed this with her line manager and the notion of a Mental Health Act (83) assessment was explored, however it was felt that this should not be pursued due to a lack of Approved Social Worker or Medical recommendation. The CPN once again contacted the Crisis Team

26 September 2007. Mr. X met with the CPN at St. James House in order to continue his assessment. It was recorded that Mr. X continued to struggle with his mood and that he had ‘blackouts’ and lapses in concentration. During this session he confessed that he often felt suicidal and that he had attempted to take his life on two previous occasions, Mr. X refused to elaborate. He did however go on to say that he definitely planned to kill himself and that the CPN would read about it in the newspapers. Mr. X was very reluctant to talk about things further but agreed to the CPN’s plan to discuss his situation with the Crisis Team.

27 September 2007. The CPN saw Mr. X at his home, on this occasion she was accompanied by a member of the Crisis Team. Mr. X no longer wanted to be seen by the Crisis Team citing the reason that he found it too distressing to talk about his problems. The CPN did however get Mr. X to agree to see the Consultant Psychiatrist to review his mental state and medication34.

28 September 2007. The CPN arranged for the Sector Consultant Psychiatrist to see Mr. X on the 1 October 2007 for an Outpatient review. The CPN also arranged to visit Mr. X at his home on the 3 October 200735.

1 October 2007. The CPN collected Mr. X from his home in her car and accompanied him to see the Consultant, the Sector Consultant Psychiatrist. The Consultant learnt from Mr. X that he was very low in mood and had suicidal ideation. Mr. X told the Consultant that his concentration was poor and that he was worried about his financial situation. He also admitted to having angry outbursts resulting in ‘black outs’ with a loss of time. He alternated between not sleeping well and sleeping for excessively long periods of time. The Consultant did not think that Mr. X was psychotic and judged him to have significant depressive, anxiety and post traumatic stress disorder symptoms. Mr. X admitted to suicidal ideation, but he would not elaborate further. The Consultant assessed him as presenting a low to moderate risk of harm to himself and a low risk of harm to others. It was noted that Mr. X’s compliance with medication had been variable and The Consultant decided to wean him off Sertraline and to commence him on Venlafaxine 37.5 mg twice daily. It was also decided to commence him on Diazepam 5 mg twice daily and Zopiclone 7.5 mg at night. The Consultant made another appointment to review Mr. X in two weeks time at the Outpatient Clinic.

3 October 2007. The CPN went to Mr. X’s home for her scheduled visit however he was not in. The CPN tried to contact him on his mobile telephone but it was switched off and left a message on his answer machine requesting that he contact her.  When the CPN returned to the Community Mental Health Team offices she discussed Mr. X with the Service Manager and a decision was made to request a ‘safe and well’ check from the local police service. The police agreed to carry out a check. Shortly afterwards Mr. X telephoned the CPN and apologised for not being in explaining that he had been in Court. The ‘safe and well’ check with the police was cancelled and the CPN arranged to meet Mr. X at his home the following week.

9 October 2007. On this day Mr. X’s Probation Officer telephoned the CPN to ascertain the formulation regarding Mr. X’s mental state. The Probation Officer informed the CPN that Mr. X’s driving license had been revoked that summer following an incident when he had a near miss with a police vehicle. On this occasion Mr. X had smelt of alcohol and became verbally aggressive towards the police officer when asked to provide a sample of breath. Mr. X refused to provide a sample of breath and was subsequently arrested and charged. Mr. X had suggested that if the Probation Services needed to know more about ‘his circumstances’ then they should contact the CPN. The Probation officer also told the CPN about Mr. X’s previous conviction when he was involved in a stabbing outside of a nightclub in 2003. The Probation Officer and the CPN agreed to liaise one with the other as required38.

10 October 2007. Mr. X’s application for naturalisation as a British Citizen was refused on the grounds that he did not know enough about the British way of life.

11 October 2007. The CPN visited Mr. X at his home. He continued to present as being low in mood and flat in effect. Mr. X stated that he still planned to kill himself but that the medication was helping. The CPN was concerned that he was taking twice the prescribed dose of his medication at night and warned him about the effects of this when combined with alcohol which she was certain Mr. X was drinking. It was clear that Mr. X was worried about his financial situation and that he wanted to return to work. However because of his prescribed medication his employer would not allow him to. It was agreed that the CPN would ascertain whether or not he was eligible to claim benefits. The CPN recorded her intention to accompany Mr. X to his scheduled Outpatient appointment on the 15 October 200740

15 October 2007. Mr. X was reviewed in the Outpatient Clinic by the Consultant. It was reported by Mr. X that he had successfully weaned himself off of the Sertraline and that the Diazepam made him feel slightly better. The CPN who accompanied Mr. X, disclosed that a close friend of his had died in Iraq over the weekend. Mr. X was close to this friend and did not want to talk about it. Mr. X told the Consultant that he was currently living at a friend’s home and that his own property was under offer and in the early stages of being sold.  Mr. X appeared to deeply resent being asked about his mood and suicidal thoughts stating that he only wanted medication to be prescribed. The Consultant discussed the possibility of a Mental Health Act (83) assessment with him and noted that he appeared to be a very angry young man who did not want to be questioned. Mr. X felt that his voluntary presence and request for medication should indicate that he did not need any further action to be taken.  At this meeting the medical opinion was that Mr. X had significant depressive and post traumatic stress disorder symptoms. He was assessed as being a moderate to high risk of harm to himself and a low risk to others. The impression was:

  1. Post traumatic Stress Disorder 2. Social problems in crisis 3. Recent bereavement 4. Unresolved psychological issues with some unhelpful personality traits

Directly following this review the CPN approached the Consultant to inform her that Mr. X had declined her offer to drive him home and had also refused her offer of a lift to his next Outpatient appointment. The CPN was very worried that Mr. X would disengage and the Consultant decided to complete a recommendation for Section 2 of the Mental Health Act (83) in order to assess Mr. X as an inpatient and to get a better idea of his mental health problems. An urgent request was made to the Approved Social Worker to facilitate a Mental Health Act (83) assessment that very evening41.

16 October 2007. The Consultant was informed that the Approved Social Worker had been unable to find Mr. X at either of his known addresses the day before. The same Approved Social Worker had informed the police of his concerns, the police had been able to contact Mr. X on his mobile telephone, and he told them he was well. The Consultant passed the request for the completion of the Mental Health Act (83) assessment to the Community Mental Health Team42

The CPN collected Mr. X and his friend in her car and drove them to St. James House to be seen by the Consultant and GP 1. The purpose of the assessment was explained to Mr. X and the reasons why it was felt to be necessary. Mr. X’s recent history was reviewed for GP 1’s benefit, this included his suspension from work, financial problems, need to sell his house, and recent bereavement. During this meeting Mr. X did not want to talk about his problems and refused to discuss his childhood as it made him feel worse when he did.

18 October 2007. A Mental Health Act (83) assessment was planned for this day. The CPN and her Service Manager had spent the previous two days trying to locate an Approved Social Worker to input into the process but were unable to do so. The Consultant had arranged for GP 1, Mr. X’s GP, to be present.

During the assessment meeting it appeared that Mr. X had very good support from the friend who had accompanied him. He told GP 1 that he had attended the meeting because he wanted medication and that he no longer had active thoughts about killing himself.  During the meeting Mr. X’s financial problems were discussed and it was felt that his Care Coordinator could help him to sort things out. It was noted that his sleep was improving and that he was eating well. It was felt that Mr. X’s mood was a bit low but that he had no thought disorder. Mr. X appeared to have some degree of depression and anxiety but stated that he had good levels of social support to help him.

It was decided that Mr. X was not detainable. The plan was for Mr. X to continue with his medication and for another appointment with the Consultant to be scheduled in four to six weeks time. The CPN was to continue supporting Mr. X in the community once a fortnight and more frequently only if required. The meetings with the CPN were to be set on a fortnightly basis as Mr. X felt that more frequent meetings exacerbated his condition. It was agreed that that CPN would next meet Mr. X on the 31 October 200743

25 October 2007. On this date Mr. X appeared at South Derbyshire Magistrates’ Court. The charge was failing to provide a specimen of breath. The date of the offence was 28 April 2007. The Court report refers to his one previous offence in September 2003 of Section 20 wounding for which he was sentenced to 150 hours Community Punishment. The Probation Service recommendation (citing Mr. X’s mental ill health) was that Mr. X should be made subject to a Community Order with the following requirements:

At this time the probation area (Derbyshire) was one of four areas participating in a pilot intervention that would mean that should he fail to comply with the terms of the Community Order and be returned to court for a breach of the order, the Benefits Agency would be informed and should the breach be proved, his benefits would be withdrawn for a four week period.

The Magistrates made a Community Order for 12 months with a condition of 80 hours unpaid work despite the Probation Service citing Mr. X’s mental ill health.  October 2007. Mr. X failed to attend his initial appointment relating to his Community Order for induction with the Probation Service. He attended three hours late because he had overslept.

31 October 2007. The CPN telephoned Mr. X first thing in the morning to remind him of his appointment, the CPN was not able to get through to Mr. X and left a message on his answering machine. Mr. X did not attend his appointment. The CPN informed both the Consultant and her Service Manager. The CPN offered Mr. X another appointment.

1 November 2007. On this date the CPN completed a Care Programme Approach (CPA) Review and Care Plan. A FACE Risk Profile assessment was also undertaken. These processes were completed in the absence of Mr. X who had not been seen by the CPN since the 18 October 2007. The CPA records that Mr. X had been placed on Enhanced CPA47.

5 November 2007. A letter was sent to Mr. X advising him that an appointment had been arranged for him to see the Consultant on the 7 December 2007.

13 November 2007. The CPN received a telephone call from Mr. X who was in ‘a state of panic’.  The CPN recorded that Mr. X had breached his Community Service Order and that his case was due to go back to court. Mr. X had been advised by his Probation Officer to ask his Care Coordinator to write a letter providing evidence as to why he was unable to comply with the terms of his Order. The CPN told Mr. X that she would discuss this with his Probation Officer. Mr. X also demanded that the CPN assisted him with his financial difficulties as his debts were mounting on a daily basis. The CPN advised him to seek help from the Citizens Advice Bureau. Mr. X became angry when he understood that the CPN was not going to help him.

The CPN telephoned Mr. X’s Probation Officer who informed her that she did not need to write a letter for the Court as Mr. X had previously agreed to the terms of the Community Order in the presence of an interpreter. It was felt that Mr. X had fully understood what had been required of him and that no mitigation could be put into place.

15 November 2007. The CPN saw Mr. X at St. James House. Mr. X presented as being very angry and spent most of the time explaining his current social difficulties. He had not approached the Citizens Advice Bureau. The CPN offered to accompany Mr. X but he declined her offer. The CPN explained that she had spoken to his Probation officer and that she felt a letter was not required from her. The CPN recorded that she ‘attempted to validate Mr. X’s anger’. He refused to discuss his mental state or the intensity of his suicidal ideation. He reluctantly agreed to meet with the CPN again on the 29 November 200750.

26 November 2007. Mr. X went to visit his GP and saw GP 1. GP 1 provided a letter for Mr. X for the Court explaining that he had slept through his Community Service Order due to the effects of his medication. Mr. X was recorded as feeling better and a repeat prescription was given for a further two weeks of medication.

Later on this same day Mr. X visited a solicitor in order to make a will. At 4.30pm Mr. X met up with his brother outside of the shop that he (his brother) owned. Mr. X’s brother stated to the Coroner that on this occasion Mr. X appeared to be ‘normal’ in his presentation, although he was a little tired and decided that he was going to go home.

Later on that afternoon at around 5.00 pm Mr. X telephoned a friend saying that he had a ‘problem’. Mr. X went to this friend’s house and was described by him as looking uncomfortable, his eyes were red and he was shaking.  The friend was concerned because Mr. X was drinking and appeared to be swallowing tablets.  Mr. X ran away out of the house and his friend telephoned the police because he was worried about Mr. X’s wellbeing. Mr. X was not seen alive again.

Mr. X was due to appear in court for the breach on this day. He had failed to attend three of six appointments offered to him and had completed eight of the 80 hours of the order imposed by the Court. The Probation Officer preparing the report for the breach appearance recommended that the unpaid work order should be revoked in view of his inability to attend in the mornings and that the Court should resentence with a supervision requirement to enable the Probation Service to closely monitor him and “access the interventions he is so obviously in need of”.

27 November 2007. Mr. X was found hanging from a light fitting at his home with the body of Ms. Halimah Ahmed on the floor beside him.