Launceston father and child sex abuse victim stabbed himself after refusing medication and counselling
It was revealed that medical notes of patients are not shared between GPs, out of hours doctors and mental health teams
Shannon Hards
A father-of-two who was abused at the age of five killed himself following 15 years of mental health struggle and refused medication and counselling, an inquest has heard.
Regular cannabis user David John Buttriss, 41, stabbed himself in front of his parents at home in Launceston on May 9, 2016.
Mr Buttriss was seen by various medical professionals in the weeks before his death and reviews have since been carried out by multiple agencies to make recommendations to prevent future deaths.
The inquest into the death of Mr Buttriss started at Truro Municipal Building on Wednesday (September 6) and senior coroner for Cornwall Emma Carlyon delivered her conclusions on Thursday.
The inquest heard evidence from 24 witnesses, including Mr Buttriss' parents, who have claimed that their son did not receive the help he needed and put on a "bravado" to make himself appear well to medical professionals.
Mr Buttris was believed to have written to the Government to promote the drug's legalisation and had also once asked his GP for a prescription of cannabis as he claimed it alleviated his mental health issues.
At the time of his death, Mr Buttriss was found to have cannabis and anxiety medication in his system, however the drugs were considered not to have affected his cognition.
Recording a verdict of suicide, Dr Carlyon said Mr Buttriss' death had identified that there were lessons to be learned and changes to be made.
She said she would write to executives at the mental health home treatment team highlighting a need to widen patient information.
She said that mental health records should be shared with GPs, both working in and out of hours and vice versa, and that GP history should be shared.
Dr Carlyon said she would be writing to ask if a more formal structure could be used by out-of-hours GPs to prompt them with the necessary questions when treating mental health patients.
She also said she would be writing to see that agencies such as the police, ambulance, GP practices and out-of-hours GPs, knew of a pathway for the mental health home treatment team, which operates out of hours.
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She added said that she would write to Cornwall Health to see that under-performance of clinicians was dealt with efficiently to ensure the delivery of effective services. Dr Carlyon also suggested she would seek evidence that there was a pathway for deficiencies in staff to be dealt with.
Proceedings uncovered that an out-of-hours doctor, who was the last medical professional to see Mr Buttriss, visited him at home two days before he took his life and wasn't able to see his medical history or notes recorded by mental health teams.
In addition it was revealed that GPs and mental health teams do not share medical notes due to data protection.
Giving evidence, Mr Buttriss' father, Michael Buttriss and mother, Erica Buttriss, expressed their disappointment at the treatment provided by out-of-hours clinician, Dr Ulrike Van Loo.
Dr Van Loo claimed she spent 15 to 20 minutes with Mr Buttriss, however his father said she had only stayed for about five minutes.
She said she believed she had attended the home to provide a prescription for medication and didn't witness any evidence of mental illness during the visit.
She added: "I saw he was rational and calm."
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Dr Van Loo said she was aware Mr Buttriss had some issues in the past but she would have been unable to view his full medical records.
She said she asked Mr Buttriss if he felt he should go to hospital and he said no.
Dr Van Loo said she left ensuring that Mr Buttriss' parents had contact details for the out-of-hours mental health team.
Dr Dean Marshall, executive director for Cornwall Heath, revealed that he advised Dr Van Loo to have further mental health training following Mr Buttriss' death.
He revealed that he would have "preferred" Dr Van Loo to contact the mental health home treatment team on behalf of the family and that she did not have a structured way of taking Mr Buttriss' medical history.
Dr Marshall said that Cornwall Health had undertaken a joint serious incident investigation with Cornwall Partnership Trust.
Dr Marshall said that, following the review, clinicians had been offered additional mental health training however as the out-of-hours GPs were not employed directly by Cornwall Health, the training was optional.
He said that the review also identified that clarification was required to inform clinicians that they are able to contact the mental health home treatment team as well as families.
Dr Marshall said the "preferred route" would have been for Dr Van Loo to contact the mental health team on Mr Buttriss' behalf.
Emma Parry, from South Western Ambulance Service NHS Foundation Trust, also spoke at the inquest and revealed that there had been a review into the hub response to the incident.
She revealed that paramedics did not attend Mr Buttriss' address within the target time of 19 minutes for an 'amber R' rated incident, due to local crews already having been occupied.
The ambulance hub was first informed of the requirement for attendance by the police, shortly after a second call was made by Mrs Buttriss.
During the second call it was revealed that Mrs Buttriss told the call handler that her son was unconscious - at this point Ms Parry said the duplicate call should have been recorded as a higher emergency classifcation.
She said that an error made by the ambulance call handler, meant that the classification of the incident was not upgraded from 'amber' to 'red'.
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She added: "It didn't affect the response time due to limited resources in the area. We now have different processes in place."
The review also revealed that when the call handler was speaking to Mr Buttriss' mother, the triage was not considered to be "safe or appropriate".
Ms Parry revealed that it was also considered that the home address was not verified properly and the call handler appeared "distressed".
Ms Parry confirmed that the desired response time wasn't achieved and said that the call handler received further training following the review of Mrs Buttriss' call.
She also said that the incident was recorded as a suicide attempt, which meant that community first responders would not have received a notification of the incident due to possible safety issues.
Ms Parry also revealed that the air ambulance would not be utilised purely because it could arrive quicker than a land ambulance.
Reg Davidson, from Devon and Cornwall Police, also independently reviewed the incident on behalf of the Independent Police Complaints Commission.
He said: "My review was that the police acted properly throughout. I listened to the 999 call and decided that the call handler dealt with it calmly, professionally and with compassion."
On Wednesday, the inquest heard that Dr Harmse at Derriford Hospital in Plymouth prepared a post-mortem examination report and gave the cause of death as a massive hemorrhage involving trauma to the neck.
Also giving evidence on Wednesday, Mr Buttriss' father said he attempted to contact the out-of-hours mental health team two days before his son's death but had difficulty getting through on the phone.
On the day of his death, Mr Buttriss said, his son had began arguing with him and his mother Erica.
Mr Buttriss claimed his son told them they were to blame for the recent break up of his relationship and referred to child abuse he had been subjected to at the age of five.
He added: "He had a knife and held it up to his throat.
"I told him I had to phone the police. While he went outside for a smoke Erica and I decided we had to call the police because we didn't know if he was going to try to hurt himself or us."
In an emotional statement, Mr Buttriss described the traumatic moments in which he watched his son take his own life.
Despite attempting to apply pressure to his son's wound to stop the bleeding, Mr Buttriss was unable to save his son.
Police, paramedics and air ambulance crews also attended the address and described the scene.
PC Gary Kellock said he saw "blood spatters on the walls and a great deal of blood pools on the carpet".
PC Michael McCune, who was the first officer on the scene, said it was clear Mr Buttriss' father had made "incredible efforts to save his son".
GP Rachel Parkinson, from Launceston Medical Centre, said she had first met Mr Buttriss in 2013 when he moved to the area from Bedford.
She told the coroner's court Mr Buttriss' medical records showed he had been experiencing mental health problems since 1992 and had previously attempted to take his own life.
She added: "He had mixed personality disorder with borderline narcissistic traits. He was well-known to Bedford mental health services.
"He believed his problems stemmed from sex abuse he was subjected to at the age of five by two teenage boys. He also had two children.
"His records also detailed substance misuse including cocaine and cannabis."
The last time Dr Parkinson saw her patient on April 18 she said he seemed "calm and rational and optimistic".
Holger Stoecker, at Launceston Medical Centre, was the last GP to see Mr Buttriss.
He said he received a phone call from Mr Buttriss' mother on April 25 and said she was "at the end of her tether".
He told the court she told him her son had been aggressive with her because she flushed his cannabis down the toilet.
Dr Stoecker saw Mr Buttriss at an appointment in the medical centre two days later which he attended with his father.
During the appointment Mr Buttriss asked Dr Stoecker for cannabis and claimed that when he stopped using the drug, his anxiety worsened.
He added that Mr Buttriss didn't present any evidence of mental illness during the appointment.
Beth Ford, interim integrated community health team operations manager, also spoke at the inquest and confirmed that a review had been undertaken following Mr Buttriss' death.
She said the review didn't identify a root cause for the death but that recommendations were made to improve how the mental heath team assessed patients.
She also said effort was being made to ensure information was being fed between GPs and mental health teams more effectively.
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