Re Sean Kay (PFD report sent to NHS Norfolk and Waveney CCG) [2021] MHLO 4

Gaps in service The coroner's concern was that a gap in service provision meant Sean fell between services and did not receive appropriate care. He had been referred by his GP to mental health services. The Early Intervention in Psychosis Team (EIPT) assessed him as not meeting their criteria for first episode of psychosis but as being in the 'at risk mental state' (ARMS) cohort of patients, which meant that his level of risk was now too high for continued work with the Wellbeing Services. He also did not meet the criteria for the Community Mental Health Team, the Crisis Team, or the charity Mind. An Interface Team Meeting did not take place because of an administrative error so at the time of his suicide six days later he was waiting to hear whether and from whom he would receive support. In neighbouring Suffolk (and many other areas) ARMS patients would have met the EIPT criteria.

Metadata from Judiciary website

29 April 2021 - Prevention of Future Deaths - Community health care and emergency services related deaths - Hospital Death (Clinical Procedures and medical management) related deaths - Mental Health related deaths - Suicide (from 2015) - PFD Report - Coroner Date of report: 28 April 2021

Ref: 2021-0124

Deceased name: Sean Kay

Coroner name: Sean Horstead

Coroner Area: Cambridgeshire & Peterborough

Category: Mental Health related deaths - Hospital Death (Clinical Procedures and medical management) related deaths - Community health care - Suicide (from 2015)

This report is being sent to: NHS Norfolk and Waveney CCG

External links


Full judgment: No Bailii link (neutral citation is unknown or not applicable)
Download here


Date: 28/4/21🔍

Court: Coroner🔍



  • NHS Norfolk and Waveney CCG🔍

Citation number(s):

What links here:

Published: 30/4/21 10:26

Cached: 2024-04-25 03:49:03