"Two days earlier, he had taken an overdose of prescribed medication and was taken to South Tyneside District Hospital."
"A Deliberate Self Harm Assessment was carried out by a doctor on Christmas Day to determine the best way of managing Mr Heslop’sdepression. "
Plunge man failed by trust
Aug 2 2008 by Paul Loraine, The Journal
THE failure by a mental health trust and other bodies to properly share information about a troubled man contributed to his death, an inquest heard yesterday.
Stephen Heslop, 22, from Marsden, hijacked a taxi at knifepoint and drove off 120ft cliffs at the Marsden Grotto car park in South Shields, South Tyneside, on Boxing Day last year.
Two days earlier, he had taken an overdose of prescribed medication and was taken to South Tyneside District Hospital.
A Deliberate Self Harm Assessment was carried out by a doctor on Christmas Day to determine the best way of managing Mr Heslop’s depression.
It was decided he was medically and mentally fit to go home but an independent inquiry into the procedures followed revealed a significant amount of important information about Mr Heslop, from Marsden was not available to South Tyneside Hospital.
Report author Lorne Carlisle, clinical Education Practitioner for Northumberland Tyne and Wear NHS Mental Health Trust, said: “In my opinion vital information was not available to doctors at the time. It became quite clear during the course of the inquiry that important information, available on an individual basis, was buried within GP reports, within mental health records, probation records and criminal justice records.”
Dr Philip Hodes, who had seen Mr Heslop a number of times in the year leading up to his death, said the doctor at South Tyneside had made a “defensible clinical decision”, while Mr Carlisle declined to judge the young doctor’s decision given the lack of information at his disposal.
Depressed Mr Heslop was in custody for three months at Holme House Prison in Teesside awaiting sentence for dangerous driving until a week before his death.
Mr Carlisle said “significant” information on Mr Heslop, who had various brushes with the law, had been gathered by South Shields probation service.
Recording a narrative verdict, South Tyneside coroner Terence Carney acknowledged there had been a collective failure by the mental heath trust, probation service, GPs and the criminal justice system, to properly communicate.
“He killed himself while suffering from a psychotic illness,” he said.
“The circumstances of his death were aggravated and contributed to by a failure to co-ordinate the essential plans and practices that were needed to ensure that this young man’s life was preserved.
“I’m sorry Mrs Heslop that you lost your son. I most sincerely hope that his loss will serve as a lesson.
“I’m fully certain that it will mean a greater robustness of approach and more co-ordination and when plans are conceived of the type which were set around your son, they will be executed with greater precision than they were in this case.”
The verdict was welcomed by Mr Heslop’s mum, Jean Costello.
After the inquest she released the following statement: “He longed to get better and be normal, and have a girlfriend and have his own home.
“He let the appropriate authorities know how he was feeling and was screaming for help. Sadly, this was denied to him from the mental health services and he went on to take his own life.
“The system has failed my son and all his family. We are totally devastated and won’t ever get over this tragedy, which we believe could have and should have been prevented, had they listened. My only wish now, as a mam, is that no other family has to go through the pain and heartache that we are going through.”
He let the appropriate authorities know how he was feeling and was screaming for help
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