East London NHS Foundation Trust is to review its procedures on mental health referrals after a coroner gave a narrative verdict in an inquest into the death of Kamil Seroka.
The 20-year-old was found dead in his home in Upper Clapton on July 10 this year. During the two-day inquest which finished yesterday, assistant coroner Heather Williams heard that his father Zbigniew had repeatedly raised concerns about his son’s mental health to doctors, the police and social services in the months leading up to his death.
The inquest heard Kamil was first referred to mental health services in November last year, by a housing support worker from One Housing, saying he was hearing and speaking to voices in his head.
However according to East London NHS Foundation Trust mental health worker Soji Ogunbula, when he arrived to see Kamil, he wasn’t in. When he did eventually manage to speak to him, he told the court Kamil didn’t want to “engage”.
The same happened months later, in June 2018, when mental health nurse Admire Mukotekwa visited him. This time, after a brief argument between Kamil and his father, the hearing heard Kamil then went inside his room, and had a brief conversation through his bedroom door.
Both mental health workers, his GP Dr Geraldine Kiela, as well as Det Sgt Mustafa, who has reviewed police evidence from the months leading up to his death, found there was no evidence of him being mentally unwell or a danger to others or himself.
Ms Williams said: “Mr Mukotekwa said the assessment was quite difficult. This seems to be something of an understatement.
“Judging whether he was psychotic was difficult in the circumstances. He asked Kamil if there was anything they could do to help him, and he said not.”
Poplar Coroner’s Court heard that police had arrested Kamil three times in the two years before his death. None of the doctors who examined him at the police station found any evidence that he was mentally unwell.
However in her evidence, Claire McElwee, from the hospital trust, who authored the serious incident report on Kamil’s death conceded there had been communication problems between the trust’s mental health teams. She said: “There had been tension between City and Hackney Adult Mental Health Referral and Assessment Service (CHAMHRAS) and the Urgent Assessment Team (UAT) over who referrals should be made to. This is something we’re reviewing.”
Ms McElwee said there had also been poor record keeping about how decisions had been made.
Even Dr Kiela said she was unsure where to refer patients.
The system for closing referrals also came under criticism from Ms Williams, after it was revealed Mr Ogunbola closed Kamil’s case in February, after he didn’t attend initial appointments. Instead, Mr Ogunbola signposted him to OffCentre, a voluntary counselling and advice centre in Hackney.
“As he had engaged with his GP, I felt this would be a service he would use,” he said.
Ms Williams said she could “understand the frustrations of his family and those who made reports that after those months there was no clear diagnosis or clear plan to assist Kamil.”
“On the occasions he was seen by mental health services or by his GP, he didn’t present any specific symptoms that indicated a psychotic assessment was required.”
However she said that even if these flaws weren’t in place, that there was “no clear evidence that it would have made any difference to the outcome.”
The coroner also ruled out any third party involvement, after his sister-in-law had read her statement to the court on November 16 saying she had received threatening phone calls after his death, and that she didn’t believe Kamil had killed himself.
Ms Williams gave a narrative verdict, saying that a lack of a note, or insight into Kamil’s state of mind on the day he died meant she couldn’t be certain about his intentions when he hung himself, despite him having suicidal thoughts in the months before.
At the end of a hearing punctuated by emotional outbursts by Mr Seroka, Ms Williams said the evidence showed Kamil was “disturbed, and unwell.”
She said she would not be issuing a prevention of future deaths notice after reading the “impressive” serious incidents report.
The says the trust will be reviewing how mental health services work together, having a senior member of staff closing referrals, and how quickly assessments are made under the urgent assessments team.
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