Bipolar patient who died was 'not triaged well'

A potential "wider training issue" at a mental health service could expose more patients to risk after one man died following care delays, according to a coroner.

David Roomes took his own life in April 2025, four months after he was referred to Kent and Medway Mental Health NHS Trust for a relapse of depression symptoms.

Kent and Medway coroner Ian Potter has expressed concern that there was initially a "significant delay" in triaging the referral and it was later "not triaged well".

The trust said it had "already strengthened aspects of our community care processes" and remained "committed to learning from this case".

Roomes, who was 67, had a longstanding diagnosis of bipolar affective disorder but his condition was "relatively well controlled with medication for a significant period" until that January last year, the coroner said.

According to his report, Roomes's family "raised numerous concerns about his mental health with staff at the trust".

Potter wrote that problems with the triaging process "had numerous implications for David's treatment later on".

The coroner said he was told the trust now provides more support for staff triaging referrals but this "did not provide sufficient reassurance" that risks were addressed.

The coroner said a previous report into another man's suicide "contained a similar concern" about a different team at the same trust, which "indicates that this may not be a localised, team-specific issue".

The person who completed a risk assessment tool for Roomes was not qualified to do so, and did not refer him to a clinician when it should have done, according to the report.

Potter said there were concerns that non-clinical decision makers were "potentially overconfident" or did not fully understand the effect of their decisions.

The coroner said there were "numerous missed opportunities" for Roomes to be seen by a clinician.

A similar patient would now be able to access care directly, he wrote, but "the concern remains that there is potentially a wider training issue".

A spokesperson for the trust said: "We are deeply sorry for the circumstances surrounding David Roomes' death, and extend our heartfelt condolences to David's family and loved ones.

"We recognise the seriousness of the concerns raised by the coroner and are carefully reviewing the findings in full."

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