Coroner critices physciatric care workers for “lack of robust action” over suicide.

A suicidal Beckley man was told by a social worker that the best thing for his depression was a brisk walk each morning.

Two days later, on June 3 last year, he was found dead, by his wife, after hanging himself from the stairs of his Hobbs Lane home, an inquest heard this week.

Proud family man, Alan Kemp, 62, a retired carpenter, became depressed and suicidal in 2008 after his retirement dream of living in France turned sour.

He was admitted to hospital in France after a failed suicide attempt before moving back to England.

Coroner Alan Craze was highly critical of social services and the mental health team, who spent just half an hour assessing Alan two days before he took his life and shortly after another suicide attempt when he tried to take an overdose.

He said they completely failed to involve Zena, his wife of more than 40 years and carer when he became depressed. She could, he said, have provided vital information, such as Alan’s phobia of hospitals.

He also said they failed to recognise that he was at risk of harming himself and admit him to hospital.

Consultant psychiatrist Dr Abdul Al-Sheikhli was evasive, and appeared confused, when asked direct questions by the coroner as to why Mr Kemp was not treated as a higher priority and admitted to hospital. He could only say: “I don’t remember”. At one stage the Coroner said: “With respect you are rambling. Just answer my question.”

Asked if she had questions of the consultant, Mrs Kemp told the Coroner: “No, now you see what I was up against”.

Dr A Sheikhli, based at The Woodlands, and Conquest based social worker Arthur Valenzuela interviewed Mr Kemp at his home two days before he died.

Mr Valenzuela said: “He did not appear to be suicidal and said that he did not need to talk to anyone.”

The Coroner said: “Even though there was a history of depression and self-harm?”

He added: “Surely Mrs Kemp would have been a good source of past information yet you asked a few brief questions to ascertain the veracity of things Mr Kemp had told you, such as was it true he only drank a glass of wine with meals.

“Surely the more information and facts you have the better.”

Asked by the coroner if he thought it was the right decision not to admit Mr Kemp, Mr Valenzuela said: “Based on our interview, based on our assessment, it was the right decision.”

The advice he was given by Mr Valenzuela was to take a brisk 30 minutes walk each morning followed by a shower.

Questioning Mr Valenzuela, Mr Kemp’s wife Zena asked: “Did it not occur to you that he had made his mind up to kill himself and that is why he was not responding to your questions?”

Mr Valenzuela replied: “That is not the impression he gave”.

She said: “He had a phobia of hospitals and would have said anything to avoid being admitted. Thirty minutes is a very short time to learn anything from him. It seems to me that having tried to commit suicide twice before it did not occur to anyone to think he may try it again.”

Mr Valenzuela replied: “He did not appear to us to be severely depressed.”

Dr Al-Sheikhli told the inquest: “There was no indication that he needed to be admitted to hospital.”

But the coroner said: “There was enough information available in another report to make it more important than to just see him for half an hour.”

He added: “After his visit to Mr Kemp, Mr Valenzuela raised concerns about him at a meeting on June 2, at which you were present but you did not take any steps.”

Dr Al-Sheikhli replied: “I don’t remember”.

Questioning Christine Lockwood, the Urgent Care Services Manager at the Woodlands Unit, the coroner said: “To put it bluntly why did you not come to a more urgent decision? The decision you made that someone would call him does not have a ring of urgency about it.”

Mark Mellor, from the NHS Trust, admitted: “There was completely inadequate involvement with his wife. The rules have now been changed.”

Stephen Lewis, from Sittingbourne Mental Health Team, who had previous dealings with Mr Kemp, said: “He blamed himself for what happened in France. He felt he had let his family down. I got the impression of a man who had worked very hard all his life.”

Neighbour Malcolm Berry said: “He seemed perfectly normal until four weeks before he died and then suddenly became quiet. He told me he could not see any future for himself, all he could see was a black hole.”

The coroner said: “I wonder if Mr Kemp may still have been with us if more robust action had been taken on June 2. But to maintain balance we have to say that at the end of the day Mr Kemp did this himself.”

He recorded a verdict that Mr Kemp had taken his life while the balance of his mind was disturbed.