A MENTAL health patient took his own life just days after a request to see a doctor and an urgent medication review for his deteriorating mental health were not actioned, a report has concluded.

David Bennett took his own life in Basildon on June 13, 2023, following a history of drug-induced psychosis that had been treated in the past with antipsychotic medication.

Sonia Hayes, Coroner for Essex, said in her prevention of future deaths report there were several areas of concern in the care he received- notably that “Mr Bennett did not receive an assessment of his mental health deterioration on June 1 or June 6 when he sought assistance and medication for his mental health deterioration”.

The 42-year-old’s family raised concerns with the GP, who advised them to call mental health crisis services on May 25.

Mr Bennett requested a GP appointment and a telephone call with the primary care mental health nurse on June 1. But, Mr Bennett’s request for medication for psychosis during that appointment was not actioned or escalated – even when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health.

She said: “Mr Bennett requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on June 1 did not escalate Mr Bennett to the GP or community psychiatrist when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health.”

At the time, there was a current prescription for antipsychotic medication on his GP records. On June 6, Mr Bennett attended the acute trust emergency department and informed staff that the mental health urgent care centre was closed.

Mr Bennett requested medication for psychosis and lack of sleep, but he was not assessed or reviewed by mental health services at the hospital and was signposted back to primary care and substance misuse services.

Mr Bennett was sent a copy of his GP summary and said he would try to access a ‘treatment clinic’.

Ms Hayes added she was also concerned the mental health crisis staff do not appear to have appropriate access to the “vital” primary care mental health records.

Paul Scott, CEO of Essex Partnership University NHS Foundation Trust (EPUT), said: “I want to send my condolences to David’s family at this difficult time. We will carefully consider the recommendations that the Coroner has made and work with partners to make the needed changes.”

Mid and South Essex NHS Trust has been asked for comment.