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Man, 22, found dead weeks after hospital discharge in shocking ‘revolving door’ mental health service ‘failure’
A MUM has revealed how her son tragically took his own life after being released by “revolving door” mental health services.
Tyler Robertson, 22, died in July 2020, less than six weeks after he left hospital following an assessment by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.
The electrician, from Hebburn, South Tyneside, was the “class clown” at school but "had problems with his mental health from a very young age", his mum Nicola said.
He was experiencing suicidal thoughts and contacted the police before going to an emergency department in South Tyneside and Sunderland NHS Foundation Trust.
Tyler was released the same day but the Parliamentary and Health Service Ombudsman found medics should have contacted his family before allowing him to leave.
She said: “Losing Tyler was devastating. You just don’t expect to lose your kids. It feels as if we don’t live now, we’re just existing.
“If he had got the right help, he might still have taken his life, but he might not have, and the not-knowing is awful.”
The Ombudsman found the clinicians should have actively approached the family for information and the level of risk may have been different had they been consulted.
Nicola said she “knew he hadn't been well for a few weeks” because of a change in his mood and mannerisms.
Tyler was also given out-of-date information for support organisations by the medics when he was assessed, the Ombudsman said.
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The longer I don’t have him, the more I miss him.
Nicola
When he tried to call, he could not get in touch with most of them.
While the Ombudsman could not say the “failings” directly led to his death, the family has been left with uncertainty.
Nicola said: “People say time makes it easier, but I don’t think it does. The longer I don’t have him, the more I miss him.
“Nothing will bring Tyler back, but I would like to think that sharing his story could stop this from happening again or at least help another family in the same situation.”
Tyler’s tragic case is just one highlighted by the Ombudsman in a damning report.
Mental health 'failures'
It said many patients with severe issues are left to fend for themselves on the outside.
People’s applications to leave secure NHS units are not assessed well enough and authorities’ communication is poor, it found.
Experts at the watchdog urged ministers to overhaul the Mental Health Act and take “urgent action”.
If people do not get proper help they are at risk of harming or killing themselves, and many end up in a “revolving door” being forced in and out of the units, they said.
Ombudsman Rob Behrens said: “Human tragedies happen when mistakes are made.
“Delaying the transfer of someone out of hospital can cause harm, but so can inappropriately discharging people too soon.
“Too often, the focus is on transferring patients out quickly, partly due to the huge strain the NHS and mental health services are under.
“But the priority must always be patient safety.
“Mental health patients are among the most vulnerable in our society and I urge the Government to act on the recommendations in this report to keep them safe.
“The lack of progress on the Mental Health Act is deeply disappointing.”
Saffron Cordery, of NHS Providers, said: "This report sheds light on the significant issues facing mental health patients leaving hospital.
“Clearly, there is more that trusts can do to improve how people with mental health conditions are discharged from hospital and supported in the community.
“Listening to service users as well as their families and carers is vital to making much-needed improvements.
“However, to really get to the root of the problem, we need to ensure mental health services – and wider services that people with mental health conditions rely on – are adequately funded and supported over the long term."
She added: “Investing in staff and the tools they need, as well as community-based services, would help people leave hospital safely, when ready, and ensure they are better supported at home.
“Focusing on these areas would also enable people to get help sooner, which could stop some from needing hospital care in the first place.
“Longstanding structural issues in mental health services must be addressed, alongside trusts making changes that are in their gift, to ensure everyone gets the support they deserve.”
It comes amid outrage that paranoid schizophrenic Valdo Calocane was discharged from mental hospitals multiple times before he knifed three people to death.
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Two reviews of mental health care in Nottinghamshire are underway after Calocane, 32, killed three people last June.
He had been sectioned four times and released most recently in 2022 before the bloody rampage, for which he was sentenced to manslaughter by diminished responsibility.
YOU'RE NOT ALONE
EVERY 90 minutes in the UK a life is lost to suicide.
It doesn't discriminate, touching the lives of people in every corner of society - from the homeless and unemployed to builders and doctors, reality stars and footballers.
It's the biggest killer of people under the age of 35, more deadly than cancer and car crashes.
Yet it's rarely spoken of, a taboo that threatens to continue its deadly rampage unless we all stop and take notice, now.
That is why The Sun launched the You're Not Alone campaign.
The aim is that by sharing practical advice, raising awareness and breaking down the barriers people face when talking about their mental health, we can all do our bit to help save lives.
Let's all vow to ask for help when we need it, and listen out for others... You're Not Alone.
If you, or anyone you know, needs help dealing with mental health problems, the following organisations provide support:
- CALM, www.thecalmzone.net, 0800 585 858
- Heads Together, www.headstogether.org.uk
- Mind, www.mind.org.uk, 0300 123 3393
- Papyrus, www.papyrus-uk.org, 0800 068 41 41
- Samaritans, www.samaritans.org, 116 123