A CORONER has said he is satisfied that steps have been taken to address issues within a mental health crisis team following the death of a young father-to-be.

Callum Cowin, 19, was discovered dead at his home in Carlisle on September 26 last year after his mum had raised concerns over his welfare.

An inquest into his death held at Cockermouth Coroner’s Court heard he had ‘significant mental health needs’. He had been diagnosed with anxiety and depression and had traits of borderline personality disorder and ADHD, which were not diagnosed.

Mr Cowin’s mum, Siobhan Emmens, said she had visited her son before going on holiday. He had recently found out he was going to be a dad but had split up with the mother of his unborn child.

He was concentrating on decorating his baby’s bedroom and had got a new job. His mum said he was in ‘good spirits’.

Ms Emmens said she spoke to her son over the phone while on holiday. However, she was later unable to get in touch with him.

Police attended Mr Cowin’s property following a referral from the council and the officer had to force entry. Mr Cowin was discovered dead.

The inquest heard that Mr Cowin was ‘vulnerable’ and a care leaver. A month before he died, he had attended A&E following an overdose.

He had been engaging with the mental health crisis team and on August 29 his risk of self-harm or suicide was assessed as ‘medium to high’.

A number of home visits had been made by practitioners from the crisis team in the weeks leading up to his death. Mr Cowin had said he was struggling with low mood.

Giving evidence at the inquest, David Storm, an associate director with Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, said a serious incident review had taken place following Mr Cowin’s death.

The review found that staff didn’t follow processes at key stages throughout Mr Cowin’s journey of care. Core paperwork, which details a patient’s mental health history and current mental state, had not been completed. Supervisors hadn’t picked up on this.

Mr Storm said a clinical lead had now been appointed who supervises assessment practitioners and goes through each patient’s records to check the documentation.

Mr Storm said the crisis team had been ‘very shocked’ to hear of Mr Cowin’s death because they felt he was ‘progressing well’.

He told the inquest: “The team is very invested in its service users. It’s a caring team. We do genuinely try to learn from what we have done wrong.”

He said the issue with the paperwork would not have made a difference to Mr Cowin’s case.

The inquest heard that Mr Cowin had expressed a desire for continuity of care.

Mr Storm said each patient is allocated a key worker but won’t necessarily see them all the time. However, they do try to reduce the number of practitioners who are involved.

The cause of Mr Cowin’s death was given as hanging. Robert Cohen, assistant coroner for Cumbria, concluded that Mr Cowin died by suicide.

In his closing remarks, Mr Cohen said he had been troubled by the evidence of the paperwork not being completed to the required standard and the communication with Mr Cowin.

But the coroner said he would not be completing a prevention of future deaths report because he was satisfied that steps had been taken to address the issues raised.

He reminded the NHS Trust that if the issues came up again, more action may be needed.  

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