The region's mental health trust still has not recognised that patients who choose not to eat or drink are at risk of ending their lives after the death of a Saxmundham man, a coroner has said.

Paul Templeton died on April 20 last year at the age of 65.

He had been care for at the Woodlands mental health unit in Ipswich since January 2023, having previously been hospitalised with a kidney injury which he acquired through not eating and drinking.

Staff at the Woodlands felt that Mr Templeton was improving. However, on April 14, he took action to harm himself, using means he found in his room. He died the following week.

Ipswich Star: Mr Templeton was being cared for at the Woodlands mental health unit in Ipswich when he took action to end his life. Image: Google MapsMr Templeton was being cared for at the Woodlands mental health unit in Ipswich when he took action to end his life. Image: Google Maps (Image: Google Maps)

The jury at Mr Templeton’s inquest found that he died by suicide.

They also found that: “Initial and all subsequent assessments seriously fail to recognise that Paul’s prolonged choice not to eat or drink were in fact indications of ‘action’ to end his own life and therefore he should have been considered as a suicide risk.”

Now, assistant coroner Peter Taheri has written to Norfolk and Suffolk NHS Foundation Trust (NSFT), which runs the Woodlands unit.

In his Prevention of Future Deaths report, Mr Taheri said that NSFT’s deputy chief executive had written to him, but that this letter had not reassured him.

The letter said: “At no point prior to or during Mr Templeton’s admission, did he present as a risk of self-harm or suicide other than through food or fluid restriction and on that basis there was no evidence to include previous history, recorded thoughts, ideation or plans to identify a risk [of suicide through other means]”.

Mr Taheri said that this response “does not grasp, engage with, or show reflection in light of the Jury’s finding”.

“The Jury’s finding was precisely that Mr Templeton did present as a risk of self-harm or suicide other than through food or fluid restriction – and that NSFT failed to recognise this risk as it was expressed by way of Mr Templeton choosing not to eat or drink,” Mr Taheri wrote.

Mr Taheri ended his report by saying that, in his opinion, further action was needed to prevent further deaths.

NSFT is required to respond to the report by May 31.

If you need urgent mental health support call NHS 111 and select option 2 or the Samaritans on 116 123. Both services are available 24 hours 7 days a week