Norwich shopping centre death raises coroner concerns
A coroner has said the death of a man who fell from a fifth floor shopping centre balcony highlights a lack of communication between health workers.
Luther Benjamin Hughes, 39, of Music House Lane, Norwich, died at Castle Mall shopping centre on 6 March.
The inquest in Norwich heard Mr Hughes had suffered mental health and alcohol problems since 2002.
In a narrative verdict, Norfolk coroner Jacqueline Lake said mental health and addiction teams failed to communicate.
Ms Lake said staff from the Norfolk and Suffolk NHS Foundation Trust and the Norfolk Recovery Partnership were in regular contact with Mr Hughes immediately prior to his death.
'Intelligent and talented'
The inquest was told that Andrew Jones from the trust visited Mr Hughes once or twice a week and had concerns about his binge drinking and admissions of taking cocaine.
This information was not passed to Stephen Taylor from the Norfolk Recovery Service who was also visiting Mr Hughes.
Micki Munro, acting locality manager for the trust, said the case had been reviewed and improvements were being put in place to improve communications between different organisations.
She said community mental health teams are reviewing care to patients who lose contact with health workers and a "hot list" will be drawn up so teams are aware of people at "high risk".
Ms Lake said: "Luther Benjamin was a very intelligent and talented man. He has been diagnosed with a schizoaffective disorder exacerbated by binge alcohol drinking.
"There are a some concerns that have been raised at this inquest. In particular there appears to have been a lack of a formal crisis plan and a lack of communication between the trust and the partnership."
Following the inquest, Michele Allott, deputy director of at the trust, said: "Our thoughts and condolences are with Mr Hughes' family and friends.
"We are reviewing how best we can support those who have severe and enduring mental health problems. We're also launching a new electronic health record that will make it easier for all our staff to share clinical information."