MORE deaths could follow if action is not taken after a man committed suicide while waiting for a GP appointment, a coroner has warned.

An investigation was opened into the death of Ronald Leslie Harris on June 14, a prevention of future deaths report issued by Herefordshire coroner Mark Bricknell said, with the inquest into his death concluding on September 27 with a verdict of suicide.

Mr Bricknell said that Mr Harris' wife had contacted Hereford Medical Group on April 24 with regards to his mental health difficulties, the symptoms of which were said to be getting worse.

The family, who were very concerned and indicated that Mr Harris' behaviour was out of character, requested further help from the surgery on April 27, and were told to expect a call the following week, the report said.

Mr Bricknell said a routine appointment was offered, which the inquest was told would be four to six weeks, but no call was made.

Mr Harris had received correspondence on May 23 in connection with cancerous lesions, but there was no reference on the documents supplied to the inquest showing his mental health position and no connection was made between his mental health position and the correspondence, the report said.

The coroner said Mr Harris had later committed suicide on June 5.

During the course of the inquest, Mr Bricknell said, evidence had revealed matters that gave rise to concern, and that it is his opinion that further deaths will occur unless action is taken.

Noting his concerns in the report, Mr Bricknell said that triage documentation had not been fully completed, and that Mr Harris had not been telephoned as requested and as advised that he would be.


The inquest was told that the triage doctor was not aware of the four to six week waiting time for a routine appointment and did not consider the transcript of the telephone call.

Mr Bricknell said the inquest was told that a significant event meeting on August 9 had indicated a review of protocol criteria for triaging patients with mental health problems was being undertaken, but that no revised protocol was advised at the September 27 inquest.

The report was sent to Hereford Medical Group, the chief coroner, and the local mental health service.

Hereford Medical Group, which must respond to the coroner in full by November 29, said: "We were deeply saddened by the tragic death that took place last July, and our thoughts remain with the family and friends of Mr Harris.

"We will be carefully reviewing the report recommendations, and we will issue a further statement in due course which will be in line with our response to the coroner"

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