Health bosses vow to 'learn lessons' after death of teenager who repeatedly said he would kill himself

The Bolton News: Jamie Nolan Jamie Nolan

MENTAL health bosses have vowed to "learn lessons" following the death of a teenager who hanged himself after repeatedly telling medics that he was going to kill himself.

Jamie Nolan was just 19 when he took his own life at the Stonham’s House Men’s hostel in Chorley Old Road on April 12.

An inquest into his death heard the former Harper Green School pupil, who had an unsettled adolescence and was homeless aged 17, had repeatedly gone to the Royal Bolton Hospital and claimed he was going to commit suicide.

His mother, Elizabeth Nolan, begged for him to be admitted, but it was decided he was of a low risk of harming himself and could be better treated in the community.

Bolton Coroner’s Court heard that heard Mr Nolan was then discharged from the care of Greater Manchester West Mental Health Trust’s crisis team on February 21 — just a day after a noose was found in the room where he was staying.

Care workers believed he had planned for the noose to be found during a room inspection and maintained that psychological therapy in the community would be the best option.

Mr Nolan was then referred to primary care psychology services — but was deemed unsuitable for this care, and at the time of his death the 19-year-old was left in limbo with just a GP responsible for his treatment.

Greater Manchester West has since carried out an internal investigation into Mr Nolan’s death and a number of changes into the way services are run have been introduced.


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Director of operations and nursing at Greater Manchester West, Gill Green, said: “Since the death of Jamie Nolan we have undertaken a detailed and thorough internal investigation as to the circumstances leading up to his death.

Jamie’s parents were able to contribute to the investigation and raise any questions they had about our services and our response to Jamie.

“We have also shared the actions we are taking to ensure that we do learn lessons and continue to develop and improve our services.”

One change, introduced since Mr Nolan’s deaths, means that referrals from the crisis team to other services can occur before a patient is discharged, meaning that there is no gap between services and no period of limbo for patients.

Speaking at the inquest, Christine Parker, assistant director for community services for Bolton Mental Health, said: “This will mean that patients are not left for a period without intervention.

“People can be referred to primary care services but if they are not deemed acceptable, there will now be a meeting to discuss what happens next.”

Mr Nolan’s step-father, Vincent Ashton said he felt this was “an obvious problem”.

He added: “Why didn’t staff point out that patients could be left in limbo if they were discharged and then not taken into primary care?”

The investigation also stated that the previous method of formulating risk assessments for patients “did not assist staff in understanding Jamie’s risk.”

Ms Parker confirmed that further training in this area has since taken place and that a new risk assessment system has been implemented.

Earlier in the inquest, assistant deputy coroner Geoffrey Saul was told how Mr Nolan had become obsessed with his health after his father was diagnosed with, and subsequently died from, the degenerative brain condition Huntingdon’s disease.

Recording a narrative verdict, Mr Saul said that “sub-optimal procedures for risk assessment and communication issues may have combined to make it harder to assess fully the risk of suicide for Jamie”.

He added that he was “satisfied” that Mr Nolan had intended to end his life on April 12.

The inquest comes after Greater Manchester West announced plans to remove 50 beds from the Royal Bolton Hospital in October in a bid to save £2.1 million.

Speaking after the inquest, Mr Nolan’s mother, Mrs Nolan said: “It was a fair judgement and I don’t think there was any other conclusion that could be reached.

“We will now consider what to do next.”

Comments (9)

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10:03am Thu 20 Feb 14

Rememberscarborough says...

Incredibly sad and I really feel for the parents. However, the lack of funding mean it would be impossible to section every person who threatens to kill themselves even if it was in the individuals best interests.

Lessons may be "learned" but are we willing to pay all the monies needed (increased taxes) to ensure that this never happens again? I doubt it.
Incredibly sad and I really feel for the parents. However, the lack of funding mean it would be impossible to section every person who threatens to kill themselves even if it was in the individuals best interests. Lessons may be "learned" but are we willing to pay all the monies needed (increased taxes) to ensure that this never happens again? I doubt it. Rememberscarborough
  • Score: 8

10:25am Thu 20 Feb 14

MissPeg says...

Rememberscarborough wrote:
Incredibly sad and I really feel for the parents. However, the lack of funding mean it would be impossible to section every person who threatens to kill themselves even if it was in the individuals best interests.

Lessons may be "learned" but are we willing to pay all the monies needed (increased taxes) to ensure that this never happens again? I doubt it.
Funding isn't the only issue, though.

The attitudes of many A&E staff when it comes to mental health is not sufficient. Some of the people paid to support people in the community are just as bad, if not worse. Then there's the fact mental and physical health are not given the same level of attention, but hopefully that will be changing with new legislation bringing the treatment of mental health more in line with that of physical health. Unfortunately legislation doesn't change attitudes.
[quote][p][bold]Rememberscarborough[/bold] wrote: Incredibly sad and I really feel for the parents. However, the lack of funding mean it would be impossible to section every person who threatens to kill themselves even if it was in the individuals best interests. Lessons may be "learned" but are we willing to pay all the monies needed (increased taxes) to ensure that this never happens again? I doubt it.[/p][/quote]Funding isn't the only issue, though. The attitudes of many A&E staff when it comes to mental health is not sufficient. Some of the people paid to support people in the community are just as bad, if not worse. Then there's the fact mental and physical health are not given the same level of attention, but hopefully that will be changing with new legislation bringing the treatment of mental health more in line with that of physical health. Unfortunately legislation doesn't change attitudes. MissPeg
  • Score: 8

2:11pm Thu 20 Feb 14

my belief says...

tragic news. thoughts and prayers to those who knew him.

i have suffered for most of my life with depression, even had a eating disorder as a kid. im now in my twenties and i have a counsellor who had me fill out forms on how i felt, i was given antidepressants, they made me ill and worse i was took off them. i was told to attend at least once a week but i cant always guarantee i can make it and especially as my counsellor is only available certain days. i studied pyschology aswell and no matter if people think someone is attention seeking or not they should be assessed. this man was let down by people who should have listened and took action, not passed the book on to someone else. shame on them! mental health is not something you can just switch off it takes time and support. His mother knew she couldnt help him and when she reached out for help she was failed too, its heartbreaking for those who care for someone with depression to try supporting but feel helpless. gone are the days of people doing their job because they want to contribute and genuinely care, but if these people who let this lad down got paid, what exactly was it for? this should never have happened.
tragic news. thoughts and prayers to those who knew him. i have suffered for most of my life with depression, even had a eating disorder as a kid. im now in my twenties and i have a counsellor who had me fill out forms on how i felt, i was given antidepressants, they made me ill and worse i was took off them. i was told to attend at least once a week but i cant always guarantee i can make it and especially as my counsellor is only available certain days. i studied pyschology aswell and no matter if people think someone is attention seeking or not they should be assessed. this man was let down by people who should have listened and took action, not passed the book on to someone else. shame on them! mental health is not something you can just switch off it takes time and support. His mother knew she couldnt help him and when she reached out for help she was failed too, its heartbreaking for those who care for someone with depression to try supporting but feel helpless. gone are the days of people doing their job because they want to contribute and genuinely care, but if these people who let this lad down got paid, what exactly was it for? this should never have happened. my belief
  • Score: 5

4:07pm Thu 20 Feb 14

127001 says...

"MENTAL health bosses have vowed to "learn lessons" following the death of a teenager who hanged himself after repeatedly telling medics that he was going to kill himself."

In todays paper I read the following article;

"POLICE used a stun gun on a man threatening to jump from a motorway bridge. The man was seen on a bridge on the M61 near to where it joins with the A666 southbound carriageway at 12:40am on Tuesday.
He was assessed by health professionals and discharged. Temporary road closures were put in place"

Yes, learning those important lessons.
"MENTAL health bosses have vowed to "learn lessons" following the death of a teenager who hanged himself after repeatedly telling medics that he was going to kill himself." In todays paper I read the following article; "POLICE used a stun gun on a man threatening to jump from a motorway bridge. The man was seen on a bridge on the M61 near to where it joins with the A666 southbound carriageway at 12:40am on Tuesday. He was assessed by health professionals and discharged. Temporary road closures were put in place" Yes, learning those important lessons. 127001
  • Score: 4

4:54pm Thu 20 Feb 14

Iluminati says...

I'm sick of health care units, quangos and politicians telling us each and every time, once a fatality or disaster has occurred in the public sector, that a lesson had to be learned. How many more lessons and how many more fatalities have occure before somebody within the health care or local authorities will finally be held accountable. Each time a baby gets mistreated and starved to death a lesson has to be learned. Each time a person dies in the mental health service a lesson has to be learned. Why oh why do we tolerate such a cover up , and incompetence!!
I'm sick of health care units, quangos and politicians telling us each and every time, once a fatality or disaster has occurred in the public sector, that a lesson had to be learned. How many more lessons and how many more fatalities have occure before somebody within the health care or local authorities will finally be held accountable. Each time a baby gets mistreated and starved to death a lesson has to be learned. Each time a person dies in the mental health service a lesson has to be learned. Why oh why do we tolerate such a cover up , and incompetence!! Iluminati
  • Score: 7

6:06pm Thu 20 Feb 14

Donkey Stone says...

Iluminati wrote:
I'm sick of health care units, quangos and politicians telling us each and every time, once a fatality or disaster has occurred in the public sector, that a lesson had to be learned. How many more lessons and how many more fatalities have occure before somebody within the health care or local authorities will finally be held accountable. Each time a baby gets mistreated and starved to death a lesson has to be learned. Each time a person dies in the mental health service a lesson has to be learned. Why oh why do we tolerate such a cover up , and incompetence!!
Totally agree. Same shallow words from many £100,000 plus a year people.
[quote][p][bold]Iluminati[/bold] wrote: I'm sick of health care units, quangos and politicians telling us each and every time, once a fatality or disaster has occurred in the public sector, that a lesson had to be learned. How many more lessons and how many more fatalities have occure before somebody within the health care or local authorities will finally be held accountable. Each time a baby gets mistreated and starved to death a lesson has to be learned. Each time a person dies in the mental health service a lesson has to be learned. Why oh why do we tolerate such a cover up , and incompetence!![/p][/quote]Totally agree. Same shallow words from many £100,000 plus a year people. Donkey Stone
  • Score: 3

3:22am Fri 21 Feb 14

BoltonLancs says...

Gill Green will continue taking her salary without hesitation knowing the problems that exist.
Gill Green will continue taking her salary without hesitation knowing the problems that exist. BoltonLancs
  • Score: 1

11:03pm Sat 22 Feb 14

Puffin-Billy says...

Councillor Andy Morgan who sits on Bolton Health Overview and Scrutiny Committee, and his party support the policies which mean that:

although the Royal College of Psychiatrists recommend an 85% occupancy rate, some wards are reaching 138%.

patients are being discharged early to free up beds resulting in one patient being re-admitted 8 times in 12 months.

the NHS is spending millions of pounds sending severely ill patients hundreds of miles to private hospitals.

a mentally ill patient had to undergo a 5 and a 1/2 hour journey to Carlisle.

acutely mentally unwell children are being admitted to adult psychiatric wards.

a mentally ill 12 year old girl shouted out of a window to her mummy who had to travel 130 miles to visit her: ‘mummy don’t leave me’.

1700, ONE THOUSAND SEVEN HUNDRED mental health beds closed in England in the last 2 years.

NHS mental health care is now in crisis, with duty workers across England reporting times when there are no beds available anywhere.

mental illness is increasing due to stress.

the number of elderly people is increasing, while services for them are being cut.

replacement services are not defined.

replacement Services have not been piloted.

replacement services are not evidence based.

there will be a net loss of jobs.

section 188 threat of redundancy notice have been given to the unions representing staff.

Councillor Andy Morgan and the Conservative Party believe the words of Jeremy Hunt who says that "...the NHS is a 60 year old mistake"

So they are now in the process of destroying it, and our health with it.
Councillor Andy Morgan who sits on Bolton Health Overview and Scrutiny Committee, and his party support the policies which mean that: although the Royal College of Psychiatrists recommend an 85% occupancy rate, some wards are reaching 138%. patients are being discharged early to free up beds resulting in one patient being re-admitted 8 times in 12 months. the NHS is spending millions of pounds sending severely ill patients hundreds of miles to private hospitals. a mentally ill patient had to undergo a 5 and a 1/2 hour journey to Carlisle. acutely mentally unwell children are being admitted to adult psychiatric wards. a mentally ill 12 year old girl shouted out of a window to her mummy who had to travel 130 miles to visit her: ‘mummy don’t leave me’. 1700, ONE THOUSAND SEVEN HUNDRED mental health beds closed in England in the last 2 years. NHS mental health care is now in crisis, with duty workers across England reporting times when there are no beds available anywhere. mental illness is increasing due to stress. the number of elderly people is increasing, while services for them are being cut. replacement services are not defined. replacement Services have not been piloted. replacement services are not evidence based. there will be a net loss of jobs. section 188 threat of redundancy notice have been given to the unions representing staff. Councillor Andy Morgan and the Conservative Party believe the words of Jeremy Hunt who says that "...the NHS is a 60 year old mistake" So they are now in the process of destroying it, and our health with it. Puffin-Billy
  • Score: 0

11:04pm Sat 22 Feb 14

Puffin-Billy says...

Councillor Andy Morgan who sits on Bolton Health Overview and Scrutiny Committee, and his party support the policies which mean that:

although the Royal College of Psychiatrists recommend an 85% occupancy rate, some wards are reaching 138%.
patients are being discharged early to free up beds resulting in one patient being re-admitted 8 times in 12 months.
the NHS is spending millions of pounds sending severely ill patients hundreds of miles to private hospitals.
a mentally ill patient had to undergo a 5 and a 1/2 hour journey to Carlisle.
acutely mentally unwell children are being admitted to adult psychiatric wards.
a mentally ill 12 year old girl shouted out of a window to her mummy who had to travel 130 miles to visit her: ‘mummy don’t leave me’.
1700, ONE THOUSAND SEVEN HUNDRED mental health beds closed in England in the last 2 years.
NHS mental health care is now in crisis, with duty workers across England reporting times when there are no beds available anywhere.
mental illness is increasing due to stress.
the number of elderly people is increasing, while services for them are being cut.
replacement services are not defined.
replacement Services have not been piloted.
replacement services are not evidence based.
there will be a net loss of jobs.
section 188 threat of redundancy notice have been given to the unions representing staff.
Councillor Andy Morgan who sits on Bolton Health Overview and Scrutiny Committee, and his party support the policies which mean that: although the Royal College of Psychiatrists recommend an 85% occupancy rate, some wards are reaching 138%. patients are being discharged early to free up beds resulting in one patient being re-admitted 8 times in 12 months. the NHS is spending millions of pounds sending severely ill patients hundreds of miles to private hospitals. a mentally ill patient had to undergo a 5 and a 1/2 hour journey to Carlisle. acutely mentally unwell children are being admitted to adult psychiatric wards. a mentally ill 12 year old girl shouted out of a window to her mummy who had to travel 130 miles to visit her: ‘mummy don’t leave me’. 1700, ONE THOUSAND SEVEN HUNDRED mental health beds closed in England in the last 2 years. NHS mental health care is now in crisis, with duty workers across England reporting times when there are no beds available anywhere. mental illness is increasing due to stress. the number of elderly people is increasing, while services for them are being cut. replacement services are not defined. replacement Services have not been piloted. replacement services are not evidence based. there will be a net loss of jobs. section 188 threat of redundancy notice have been given to the unions representing staff. Puffin-Billy
  • Score: 1

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