Marlon Demaine was assessed three times by different mental teams in the 36 hours before his suicide at his Chelmsley Wood home
A ‘wonderful and caring’ grandad took his own life just hours after being assessed by a mental health team who deemed him ‘not at serious risk’.
Marlon Demaine was assessed three times by different mental teams in the 36 hours before his suicide at his Chelmsley Wood home.
An inquest at Birmingham Coroners Court heard how the 50-year-old had told his son James Lyons in ‘graphic detail’ of his intensive suicidal thoughts in the early hours of June 28.
The family told Coroner Emma Brown that they asked for Marlon to be admitted to hospital as they had serious concerns about his deteriorating mental health.
But despite three assessments in 36 hours, he later jumped from a window on June 29. He died two days later at University Hospital in Coventry from multiple injuries.
The court heard how in the early hours of June 28 Marlon, who suffered with bi-polar and schizophrenia, had stood on the window ledge in his flat but was talked down by his son.
Mr Lyons told the court: ‘I went to his flat and when I managed to get in Dad was standing in the hallway with the front door wide open.
‘He was completely unresponsive and he didn’t know who I was.
‘He was describing that his world had ended and then in graphic detail the ways that he would commit suicide.
‘He then jumped onto the ledge and I had to drag him down. My Dad’s had mental health episodes like this before but never anything like this.
‘Paramedics arrived and after talking to him for about 20 minutes his mood started to stabilise and they agreed he should be taken to A&E.’
Mr Demaine was taken to Heartlands Hospital by paramedics where he was assessed by the RAID team in A&E by nurse Sanya Dixon-Graham.
But after telling her he was ‘no longer having suicidal thoughts’ he was discharged with a referral to a community physiatric visit, due to take place later that day.
Yet when no contact was made Mr Demaine’s ex-partner Jessica Reinold visited the Newington Centre in Marston Green to ask that he be admitted as an inpatient.
Mr Demaine’s ex-partner Jessica Reinold(pictured with her daughter Annabel) visited the Newington Centre in Marston Green to ask that he be admitted as an inpatient
‘That day when I went to see Marlon he looked terrible,’ said Jessica.
‘[In the assessment] Marlon said that he felt he was going insane, insane to the point of no return. I emphasised I was extremely concerned.
‘In 26 years I had never seen him like this, he had spiralled.’
His family explained to the duty nurse at the Newington Centre that they had serious concerns about Marlon and staff asked that they bring Marlon in for an assessment.
Mr Demaine was then assessed by nurse Simon Wills that afternoon who told the inquest he recalled that he had a fluctuating mood and had become more depressed over recent weeks after a relationship break-up.
Mr Wills recalled that Mr Demaine has claimed ‘I’m living a lie. I’ve never loved anyone’.
But again Marlon was sent home, with a visit by a Home Treatment Team scheduled for the following day.
Mr Wills told the court: ‘I’ve thought about it every day since and knowing what happened now, if I could see the future, it would have been different.’
The Coroner told Mr Wills she ‘was troubled’ that he did consult for a further physiatric assessment, when just hours earlier Marlon had to be talked down from a window ledge.
But he added that he stood by his decision to send him home as he claimed that he was not presenting any signs that would ‘warrant an admission’.
The next day the Home Treatment Team visited Marlon at his flat, but again decided not to admit him.
Two hours after that appointment he jumped from the window of his flat.
Birmingham and Solihull Mental Health Trust launched an investigation following Marlon’s death
Dr Pramodh Samuel, who was part of the home treatment team, admitted that he had not questioned Marlon about the incident just 36 hours later where he had jumped on the window ledge.
He said: ‘He didn’t say much. He was in a low mood. He denied any thoughts of suicide or self harm.
‘I didn’t ask him [about the incident with the ledge]. He wasn’t in a state to explain, he was confused.’
Dr Samuel referred Marlon for daily visits from the Home Treatment Team.
But just two hours later a member of the public would dial 999 after witnessing Marlon jump from his flat.
Birmingham and Solihull Mental Health Trust launched an investigation following Marlon’s death, which found that his family’s concern should have been more heavily weighted.
A Root Cause Analysis (RCA) report, led by Nurse Consultant Kerry Webb, also found a member of his family should have been invited to attend a review appointment on June 12.
Area Coroner for Birmingham and Solihull Emma Brown said she was concerned that the Home Assessment Team had not discussed Marlon climbing onto the window ledge before his son talked him down, when Dr Samuel admitted he had knowledge of the incident from his notes.
She said: ‘One does not see more extreme suicidal behaviour than that.
‘It was known that he would mask his illness, and those that knew him best thought that this is what he was doing.
‘I cannot understand why this incident would not have been discussed when it was important to understand why Marlon had done this.’
Recording a narrative conclusion, Miss Brown said: ‘Marlon died as a result of suicide, where the risk of suicide had not been correctly assessed and managed by mental health services.’
Following the inquest Jessica said: ‘It’s been a nightmare, and the whole family is devastated.
‘Today is has really hit home that we have lost an amazing man who was loved by all of us.
‘The mental health services didn’t take proper care of Marlon, and didn’t listen to us when we told them that he was at serious risk.
‘We were very pleased with the RCA report, which we thought was very fair and honest.
‘If they had listened and taken us seriously then things would have been different.’
- For confidential support call the Samaritans on 116 123, or visit a local Samaritans branch – see samaritans.org for details.