A man who took his life had “incorrect prioritisation” for mental health care due to information not being shared in a timely way between IT systems, a coroner has said.
John Michael Kirkman, 36, died on December 27, 2023. He had paranoid schizophrenia, “which was difficult to control despite appropriate medication”, wrote Professor Paul Marks in a Prevention of Future Deaths Report.
Prof Marks, senior coroner for Hull and East Yorkshire, wrote that Mr Kirkman had a history of “detentions and admissions” under the Mental Health Act.
Before his death, Mr Kirkman researched a toxic substance which he arranged to be bought on his behalf. He ingested the poison in the early hours of December 27, with the knowledge this “would result in death”, wrote Prof Marks.
Mr Kirkman had assisted living arrangements, but “there was no realistic opportunity to have saved his life by the staff at the home”, said the coroner.
The report found that, because of variations in IT systems used, mental health screening assessments carried out in one part of the country “may not necessarily be immediately available in another part of the country”.
It added: “Absence of vital background information could result in an incorrect prioritisation for onward referral, as it did in this case.”
The report, sent to the chief executive of NHS England, said the organisation should take action, such as by “reviewing the compatibility of IT systems”. NHS England has until September 2 to respond.
Earlier this month, NHS England unveiled plans to roll out a single patient record across the NHS, as outlined in Fit for the Future: The 10 Year Health Plan for England.
An NHS England spokesperson said: “NHS England extends its deepest sympathies to the family and friends of John Michael Kirkman.
“We will carefully consider the Prevention of Future Deaths Report sent to us by HM Coroner and will respond in due course.”