Gareth Etchells-Height: ‘Missed opportunities’ in mental health care of Sheffield man who took his own life

An inquest into the death of a man who was receiving treatment for his mental health has found 'missed opportunities' in his care.

Gareth Etchells-Height was aged 42 when he was found unresponsive by staff members at a residential step-down facility in Sheffield, on April 24, 2022. Despite best efforts by staff members and paramedics to revive him, he was sadly pronounced dead.

Assistant coroner for South Yorkshire West, Alexandra Pountney, heard evidence over three days at Sheffield’s Medico-Legal Centre in relation to Mr Etchells-Height’s death, as well as a number of concerns over his care raised by the family.

In a narrative conclusion on October 31, Coroner Pountney said that Mr Etchells-Height had intended to take his own life, but that there were 'various missed opportunities' during his care, one of which was found on the balance of probabilities to have contributed to his death.

Mr Etchells-Height, who had been diagnosed with Asperger's, had a history of mental health problems, and had attempted to end his life on several occasions. In the months leading up to his death, Mr Etchells-Height experienced a deterioration in his mental health.

On February 17, he was taken to the Longley Centre, at Northern General Hospital, for an urgent mental health assessment after British Transport Police found him on railway tracks in the city.

The assessment found Mr Etchells-Height was presenting with symptoms of psychosis. He said he did not feel safe to return home, and wanted to be admitted. It was also noted he had increased his use of cannabis, and it was unclear whether the psychosis was drug-related. Despite this he was not admitted.

Coroner Pountney said this was a missed opportunity to properly assess Mr Etchells-Height’s condition, as usual practice would see a patient monitored for two to three days to rule out drug-induced psychosis.

Another missed opportunity was noted when it was found that Mr Etchells-Height’s family were not contacted to get additional information, which was also usual practice following an assessment.

The following day, Mr Etchells-Height was brought back to the Longley Centre by the police. The assessing team said his paranoid beliefs had intensified, and he was admitted to an acute mental health inpatient ward known as Maple Ward.

Mr Etchells-Height remained on the ward until March 22, and Coroner Pountney found that staff provided "appropriate and adequate" care.

He was diagnosed with unspecified non-organic psychosis and he was started on an antipsychotic drug known as olanzapine, which was later increased. There were "fluctuations" in his mood and behaviours while on the ward, but it was found that his mental health was "settled".

He was discharged to Wainwright Crescent, a step-down facility where service users can focus on their recovery with support from staff before they are discharged back into the community.

Coroner Pountney found that the handover process between the two wards was "insufficient", and the discharge notes did not mention his new diagnosis, leaving the staff at Wainwright Crescent "effectively working blind", without a clear picture of his health. However they provided "adequate care and support".

Sadly, his mental health began to deteriorate once again and he was found to not be taking his medication. Coroner Pountney said: "It is important to remember that if a person has capacity, there is very little that mental health services can do to ensure compliance with medication."

A 'plethora of missed opportunities' were noted by the early intervention service, which was the community mental health team identified to support Mr Etchells-Height while at Wainwright Crescent. This included failures to assess him face-to-face, opting for telephone appointments instead; a failure to update his risk assessment; and failure to tell Mr Etchells-Height that he would be able to stay at Wainwright Crescent a further week after his scheduled discharge (April 25).

"This would likely have reduced Gareth’s distress around the period of April 20 to April 24 had he been provided with this information," Coroner Pountney said.

"I am satisfied that this failure more than minimally contributed to Gareth’s death on April 24, 2022."

Martha O’Toole from Taylor Emmet Solicitors, who represented the family, said: “Firstly, our thoughts are with Gareth’s family and loved ones who have been through the most agonising time. They have shown such courage in adversity over the last year and a half.

“Gareth was an incredibly special individual. He was an interesting person and had his special interests, which included buses, and could tell you anything about a certain bus, including its number, fleet, where its garage was situated and the type of engine it had. Notwithstanding Gareth’s neurodiversity, he worked in various jobs and was an intelligent and capable individual. His parents, Caroline and Michael, and brother, Alex, cherished him and miss him very much.

“We hope that [Coroner Pountney's] findings and conclusion will go some way to assisting Gareth’s family and friends through the grief process.”

Prevention of Further Deaths report

On November 11 2023, Coroner Pountney issued a Prevention of Further Deaths report to Sheffield Health and Social Care Trust. Her concerns were outlined as followed:

- Discharge and safety netting: The discharge report for Gareth was 'not fit for purpose' and did not contain details of his diagnosis or sufficient information about high-risk behaviours/triggers.

- Review of the medical notes: There was wholesale inconsistency in healthcare professionals reviewing medical notes before appointments, assessments, or handovers for Gareth. There was no written guidance on this issue and it lead to Gareth being seen by healthcare professionals who did not have an up-to-date understanding of Gareth’s condition and mental state.

- Failure to update risk assessment: There was a failure to update Gareth’s risk assessment, which at the date of his death was last updated on 7 April 2022.

- Record Keeping: There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth.

If you have been affected by any of the issues raised in this article, the Samaritans is able to help – the charity’s free helpline number is 116 123.