Coroner finds lack of action by healthcare professionals exacerbated 18-year-old’s mental health deterioration

15 November 2023

The inquest into the death of 18-year-old Bhagat (“Buggy”) Singh was concluded by HM Assistant Coroner for Newcastle and North Tyneside, Paul Dunn, on 25th October 2023.

Buggy died by suicide on 19th October 2022. At the time he was under treatment from Cumbria, Northumberland, Tyne and Wear Foundation Trust (CNTW), having been discharged from the Trust’s Child and Adolescent Mental Health Services (CAMHS) earlier that year.

During the course of the inquest, the coroner heard evidence in relation to:

  • Buggy’s contact with members of college staff and the institutional response to self-reported thoughts of suicide;
  • college safeguarding policies and processes;
  • Buggy’s contact with CNTW, third-party mental health services and his GP, and whether there was an adequate plan for his care;
  • whether information in relation to Buggy’s deteriorating mental health and his risk was communicated between agencies.

Buggy had diagnoses of autism spectrum disorder, dyspraxia, hypermobility and obsessive compulsive behaviours. The court heard that he had to wait a number of months for an assessment by CNTW mental health services following his discharge from CAMHS, despite his mother’s increasing concerns that his mental health was deteriorating.

The coroner found that there had been a missed opportunity to share information following an assessment by CNTW Community Treatment Team on 12th October 2022. The required documentation was not completed following the assessment and Buggy was not discussed in subsequent MDT meetings as he should have been. As a result, his care or treatment was not progressed following the appointment.

On 18th October 2022, Buggy attended a field trip, but was taken back to college after making a number of statements to college staff which indicated that he was at a significant risk of suicide. He was taken home by his mother, who contacted the CNTW Crisis Team. Despite a number of warning signs, the Crisis Team did not consider Buggy to be at imminent risk of suicide.

The coroner found that multiple pieces of information demonstrated that Buggy was at substantial risk of harming himself at this time, and that his mother was ‘crying out for help’ when she contacted the Crisis Team. The coroner found that a simple piece of advice not to leave Buggy on his own may well have prevented his death on 19th October 2022.

HM Assistant Coroner Dunn gave a narrative conclusion, highlighting the lack of action by healthcare professionals to act on the imminent risk that Buggy presented.

Lily Lewis represented Buggy’s mother at his inquest, instructed by Dawn Makepeace of Watson Woodhouse Solicitors.

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