Rupert’s mother raised the alarm with his carer in the hours before his death
An aristocrat’s skunk-addicted son took his own life after a mental health team ‘failed’ to give him proper care in the days before his death, a coroner ruled today.
Rupert Green, 21, the son of Lord Nicholas Monson, died in January 2017, five days after he hanged himself in his mother’s garden in Farnham, Surrey.
A coroner today said the mental health trust failed to refer him to a special service which could have watched him more closely before his death.
Mr Green was refused an assessment by Surrey and Borders NHS Trust’s home treatment team three days before he hanged himself.
A nurse rejected the referral, made by the Safe Haven mental health centre, despite his claim that there would be ‘blood’ on his mother’s hands if people did not believe he was the son of God.
The tragedy happened after the Lord Monson’s first son, Mr Green’s half-brother Alexander Monson, 28, was allegedly killed in police custody in Kenya.
Mr Green, 21, the son of Lord Nicholas Monson, hanged himself at his family home in Farnham
Lord Monson launched a ‘war against skunk’ after Mr Green’s death, urging ministers to decriminalise weaker strains of cannabis to prevent abuse of stronger strains.
Coroner Anna Crawford said: ‘There was a failure on the part of the home treatment team to accept the referral made to them by the nurse at the Safe Haven centre.
‘It’s more likely than not that they would have had intensive contact with Rupert from that time onwards.’
She added: ‘I accept that this would have resulted in regular, in all likelihood daily, contact with him, providing an opportunity to further assess his presentation risk and the compliance otherwise with his medication.’
Lord Nicholas Monson and Mr Green’s mother Karen Green – above, in Woking in Wednesday
But she did not say the failure caused Mr Green’s suicide.
Ms Crawford said: ‘I cannot from the evidence before me conclude that it is probable they would have intervened in a sufficient time.’
The coroner also said Mr Green received a ‘good standard of care’ before he was refused the check-up on January 15.
She said she was ‘not persuaded’ there was a failure to admit him to hospital.
But she added: ‘I consider that it is at least agreeable that the trust knew or should have known there was a risk to Rupert’s life.’
Addressing Mr Green’s mother, Karen Green, after concluding he died from suicide, she added: ‘You did everything within your power to seek help for your son, which you so clearly knew he needed, and I commend you for that.’
Ms Crawford said it was ‘at least agreeable’ there was a breach of Article 2 of the European Convention, which states a right to life.
Lord Monson had earlier told the three-day inquest his son’s psychosis had deteriorated his mind to a childlike state. ‘He was a very good artist,’ he said.
‘He had been painting (recently) and it was as if he had reverted to being a four-year-old child and I thought, ‘this poor young man’.’
Mrs Green also claimed that she texted his care coordinator, Faye Brevitt, for help hours before he hanged himself but received no reply.
She said: ‘I think I said Rupert warned I would have blood on my hands for not believing he was the son of God.’
She said she deleted the texts after Mr Green’s death, but added: ‘My phone records confirm the text message was sent, I didn’t receive any response.’
The coroner was told the missed opportunity to refer Mr Green to the home treatment team was because a nurse said his condition was ‘not a crisis.’
He visited the Safe Haven walk-in mental health centre in Aldershot, Hampshire, on January 15 and nurse Diane Evdoka tried to have him referred to the team.
But when she phoned Vimbai Vhondo, a nurse on the team, she refused to see him that day despite his psychosis.
Alison Blofield, a consultant nurse who carried out an independent review into Mr Green’s death, said he should have been seen.
During the inquest, the coroner asked Ms Blofield: ‘A combination of his presentation and what he was saying about harming himself would, in your view, have been sufficient to justify a home treatment assessment on the day?’
She replied: ‘Yes, most definitely.’
The coroner said a prevent future deaths report will now be considered.
Later, reacting to the coroner’s verdict, Lord Monson said: ‘I am relieved that the coroner has ruled that the Surrey and Borders NHS Trust failed to take reasonable measures with Rupert from January 15. Given the weight of evidence, I would have been surprised had she ruled otherwise.’
Speaking from Spain, he added: ‘Personally, I do not blame all those working within the Trust involved with Rupert in the final days of his life.
‘The duty nurse on January 15 stands out as heroic in her efforts to find support for her recommendations of care for Rupert and should be commended. I hardly need state what I feel about those who resisted her strong recommendations.
‘Separately the coroner says a breach of duty of care is arguable. I agree and this breach of duty of care, which Rupert’s family allege, will doubtless be argued in a separate legal arena.
‘On a wider issue it should be remembered what brought Rupert to his sorry psychotic state and led to such drastic self-harm.
‘It was a heavy historic ingestion of high potency cannabis, referred to as skunk. Some people are under the impression that Rupert was still consuming it just before he died. They are wrong.
‘It was the mid to long term psychological after-effects of his habit that led to his appalling mental derangement. He had not touched skunk for at least three months.
‘This should strongly be considered by everyone bringing up and educating teenagers. Skunk greatly reduces mental capacity at the very least and can cause long to lifetime mental disorders, an outcome which is tragic for the afflicted and their families.
‘I urge mandatory education on the matter. Best of all we should get skunk off the streets. To achieve this, I advocate legalisation of much less damaging low potency cannabis to eradicate skunk.
‘It was legalisation in 1932 of all previously prohibited alcohol which destroyed the US market in moonshine whiskey, skunk’s alcoholic equivalent. If there is another way of getting skunk off our streets and away from our teenagers, I have yet to hear it.
‘Politicians who continue to maintain an inert response to the scourge of skunk deserve to be kicked.’
Also following the case, Justin Wilson, Chief Medical Officer at Surrey and Borders Partnership NHS Foundation Trust, said: ‘I am deeply sorry for Rupert’s tragic death and my thoughts are with his family at this difficult time.
‘Our serious investigation into the care and treatment provided to Rupert has shown that the communication between our Safe Haven service and Home Treatment Team was not clear and requires improvement.
‘We acknowledge the findings of the coroner that there was a missed opportunity for more intensive support from our Home Treatment Team and have worked closely with the services involved to make positive changes.
‘Rupert was assessed by a consultant psychiatrist and his care coordinator the day after his attendance at our Safe Haven and a support plan was agreed.
‘Evidence shows that the use of cannabis can increase a person’s chance of experiencing psychosis and we support any awareness campaigns that highlight the dangerous impact of these illegal substances.’
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