Prevention of future deaths report: Nicolas Gerasimidis (12 February 2024)

Summary

Nicholas Gerasimidis had a history of mental illness manifesting as obsessive compulsive disorder (OCD) and anxiety. In 2022, his condition deteriorated. His GP referred him twice to the Community Mental Health Team but the referrals were rejected with medication being prescribed instead, together with advice to contact Talking Therapies.  

He was taken on to CMHT workload after being assessed by the Psychiatric Liaison Team in Royal Cornwall Hospital in November 2022. The preferred course of treatment was psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention. There was a waiting list of a year. In May 2023, Mr Gerasimidis became worse. It was felt an informal admission to hospital was required but a bed was not available. He was found hanged at his home address on 3 June 2023.

Content

The MATTERS OF CONCERN are as follows.

The Trust’s Patient Safety Review identified the following concerns:

• When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues.
• No care coordinator was appointed owing to a shortage of staff.
• The Trust had and continues to have vacancies at consultant leve.
• The family was wrongly advised the Trust was not commissioned to treat OCD.
• The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP.
• Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year.
• In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.

The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.