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Concerns Ignored: Man Dies After Multiple Mental Health Referrals
27 Feb
Summary
- Multiple referrals were made before Tyran Jones' death.
- Mental health professionals allegedly ignored critical concerns.
- The inquest heard Tyran Jones was autistic and known to services.
An inquest revealed multiple concerns were raised about Tyran Jones, a 30-year-old man with mental health issues, in the days leading up to his death by suicide at his Northfield, Birmingham home on March 30, last year. Referrals were made by an ambulance service, a housing association, a charity, and Birmingham Edgbaston MP Preet Gill. Jones, who was autistic, had been under the care of mental health services for at least a decade, with specialist community teams supporting him at the time of his death.
Dr. Ellis Hamilton noted past suicidal ideation and overdose incidents, alongside Jones' concerns about hormone levels and fertility. During a March 24 appointment, Jones expressed a desire not to live after a recent breakup and admitted to an overdose the previous weekend. However, the GP concluded he wasn't at immediate risk due to a scheduled medical procedure the next day. Birmingham City Council confirmed Jones had been known to adult social care since 2015 and was detained under the Mental Health Act twice in 2024.
It was deemed 'unusual' and 'sub-optimal' that Jones was in a general hospital rather than a psychiatric facility. In January of this year, Autism West Midlands referred Jones to council services, placing him on a waiting list. Further referrals followed on March 20 from West Midlands Ambulance Service and on March 28 from Autism West Midlands, Clarion Housing Group, and MP Preet Gill. The MP's letter was unfortunately not opened until after Jones' death due to its late arrival on a Friday.
Dr. Ilemobayo Fapohunda last saw Jones on March 27 and felt he was in a better place following a successful medical procedure. He believed Jones could be safely managed by his community mental health team with crisis numbers provided. Despite this, the family pushed for a narrative conclusion, citing unaddressed referrals. The assistant coroner, however, concluded death by suicide, stating he was satisfied with the hospital's learnings and improvements for neurodivergent patients.
