Man who jumped to his death from Norwich’s Castle Mall was let down by mental health services, inquest told — (Norwich Evening News)

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Norwich Evening News

By David Bale

Thursday, September 5, 2013

A coroner has criticised a mental health trust for failing a man who jumped to his death from the Castle Mall shopping centre in Norwich.

At yesterday’s city inquest, Norfolk coroner William Armstrong criticised the Norfolk and Waveney Mental Health Trust for “fundamental deficiencies” in the way it treated Matthew Dunham, 25.

Mr Armstrong said support had been “fragmented and unco-ordinated” with mental health staff not aware they were treating Mr Dunham at the same time, and therefore not sharing information.

The coroner also expressed concern that an emergency GP referral that should have been followed up within four hours, instead took two days.

He said: “There is evidence of a disturbing nature as far as mental health services are concerned.

“There was no lack of help being given to Mr Dunham, but the care and support was clearly fragmented and unco-ordinated. The evidence reveals problems accessing information and about sharing information. These are fundamental deficiencies and serious inadequacies that must be addressed. It’s alarming that information about a patient’s care was not being shared.”

He concluded that Mr Dunham intended to kill himself, but added that it was while suffering from a mental disorder and while in receipt of mental health services.

A spokesman for the trust said at the inquest that changes were ongoing to rectify the concerns raised to ensure that it would not happen again.

Earlier, the inquest was told how shocked shoppers at Castle Mall were left traumatised by what happened, at about 7.20pm on May 9.

Mr Dunham had jumped from the fifth floor of the shopping centre landing on the ground floor level, and despite the best efforts of medical staff, he died at the scene.

The inquest heard that Mr Dunham, who was an IT web designer, lived alone at a flat in St Augustine’s Street, Norwich.

Just seconds before he jumped to his death, he texted friends saying, “It’s over. Thank you all for being amazing friends. I would not have lasted this long without you.”

 Note: Toxicology report showed antidepressant in his blood.