Benjamin Sulzbacher: Prevention of future deaths report

Suicide (from 2015)

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Date of report: 15/05/2024

Ref: 2024-0268

Deceased name: Benjamin Sulzbacher

Coroner name: Joanne Kearsley

Coroner Area: Manchester North

Category: Suicide (from 2015)

This report is being sent to: Department of Health and Social Care | Priory Head Office | Greater Manchester Integrated Care Board

1. The Rt Hon Victoria Atkins, Secretary of State for the Department of Health and Social Care
2  [REDACTED] Chief Executive Officer, Priory Head Office, Floor 5, 80 Hammersmith Road, London W14 BUD
3. [REDACTED] , Chief Executive, NHS Greater Manchester lntegrated Care Board
I am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North
I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On the 9th October 2023, I commenced an investigation into the death of Mr Benjamin Sulzbacher who died on the 27th September 2023. The investigation concluded on the 2nd May 2024. The medical cause of death was confirmed as 1a) Hanging. A conclusion of suicide was recorded.
Mr Sulzbacher had suffered from a deterioration in his mental health for a number of years. This became more acute during 2023. Throughout this time he had accessed assistance from professionals within his community and this was done on a private basis.

On the 24th August 2023 having tried to tie a ligature at home, he was taken to the Accident and Emergency Department at North Manchester General Hospital. He was assessed and it was recognised he required an inpatient admission which he agreed to as a voluntary patient.

Due to the only available acute inpatient bed being in the South, his family funded a private admission at the Priory hospital in Altrincham. He was an inpatient from the 26th August until the 18th September 2023.

On. his discharge from the Priory part of the discharge plan was for a follow up phone call within 48 hours. This occurred on the 21st September 2023. Learning from how this call was conducted has already been recognised by the Priory.

The court heard evidence that no referral was made to the NHS mental Health trust for follow up via the Home Based Treatment Team. In this case due to where Mr Sulzbacher lived, a referral would have been to Pennine Care NHS Trust Foundation Trust. This would have occurred automatically if he had been an NHS inpatient.                    
The court heard if a referral had been made to the Home Based Treatment- Team they would have conducted a face to face follow up within 72 hours and if necessary, would have remained engaged with Mr Sulzbacher for up to 4 weeks. The court also heard evidence that the NHS Trust would have accepted such a referral even though Mr Sulzbacher had been a private paying inpatient.

The evidence from the family was that Mr Sulzbacher’s mental health declined on his return home and he died having tied a ligature on the 27th September 2023.
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. ·1n the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
For the Priory
1. There was a lack of understanding from the Priory witnesses as to what the NHS community services could offer on discharge. The court heard that the Home Based Treatment Team was understood to simply be a “Crisis team” which was incorrect.

For All:
1. It was unclear to all services as to whether a private paying inpatient (who would have qualified for care under the NHS but due to bed availability went private) would be entitled to be referred to the discharge services offered by the NHS. The NHS provides more than the private sector in respect of community discharge packages and can be engaged with someone for longer. Importantly the face to face contact enables a better understanding of how a patient is actually presenting when considering their mental health.
In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely
12th July 2024. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:­ Family of Mr Sulzbacher
Pennine Care NHS Foundation Trust
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.