Coroner concerned after death of mentally ill man

Jacqueline Lake said that opportunities to provide appropriate care to Christopher Sidle were missed

A coroner has raised concerns about the circumstances surrounding the death of a man with mental health difficulties who threw himself out of a moving taxi.

Jacqueline Lake, senior coroner for Norfolk, concluded after an inquest that opportunities to provide appropriate care to Christopher Sidle were missed.

She has issued a prevention of future deaths report and sent it to the Norfolk and Suffolk NHS Foundation Trust. She said there was a risk that "future deaths could occur" unless action was taken.

Cath Byford, from Norfolk and Suffolk NHS Foundation Trust, said: “Learning from deaths is our top priority."

'Understanding'

Mr Sidle, who came from North Walsham, Norfolk, had been diagnosed with paranoid schizophrenia, and died in July 2023 after jumping out of a taxi travelling at about 30mph and sustaining life-threatening head injuries.

Mrs Lake has raised a number of concerns.

She said that there "remains a lack of understanding" amongst a Crisis Resolution Home Treatment Team (CRHTT) with "regard to assessing a person’s mental capacity to make decisions" and to record the rationale for making decisions.

"Important emails" had not been circulated to "relevant personnel" within the CRHTT, she added.

Mrs Lake had said in March, after an inquest, that the cause of Mr Sidle's death was "traumatic brain injury" and "schizophrenia".

She had concluded that there were "missed opportunities to provide appropriate and timely care" and that mental health assessments had been "inadequate".

'Action'

"During the course of the investigation my inquiries revealed matters giving rise to concern," said Mrs Lake in her prevention of future deaths report.

"In my opinion there is a risk that future deaths could occur unless action is taken."

She added: "It is clear that the NSFT have treated the circumstances surrounding Christopher’s death seriously and have carried out an internal investigation, made recommendations and have put in place steps to prevent future deaths.

"However, there do remain outstanding matters of concern."

Mr Sidle's family said he experienced his first episode of psychosis in December 2011

After the inquest in March, Mr Sidle's relatives issued a statement and photographs of him through their lawyer, Tom West, who is based at Ashtons Legal.

"We remain of the view that Chris’ death was entirely avoidable," their statement said.

"We expect the trust to take the coroner’s findings seriously.

"It must follow through with its action plan to address the failings that have been identified."

'Psychosis'

Ashtons Legal had said Mr Sidle had worked for the government as a climate change officer before experiencing his first episode of psychosis in December 2011.

"Mr Sidle died on 4 July 2023 as a result of injuries sustained when throwing himself from a moving car three days earlier," said the firm in a statement.

"At the time of the incident, he had been suffering from a period of psychosis for over three months."

Cath Byford, the deputy chief executive at Norfolk and Suffolk NHS Trust, said: “Our thoughts remain with Christopher’s family at this very difficult time.

“As a trust, we are on a rapid, and much needed journey of improvement which has been strengthened by the welcome arrival of our experienced chief executive officer, Caroline Donovan."

She added: “Learning from deaths is our top priority as a trust. We have previously outlined the actions we have taken since Christopher’s death, including further training for our staff, redesigning our triage tool and patient history recording systems to ensure our staff deliver the best care they can for our service users.”