image captionBlack Country Healthcare NHS Foundation Trust said the report was compiled by author Michele Paduano, BBC Midlands Today
55 minutes ago
The man's death is being investigated by a mental health trust after it emerged the crisis team failed to take action despite multiple reports.
Heron Wall, 49, took his own life in West Bromwich on February 18 this year.
It has emerged that in the months before his death, doctors had repeatedly requested support for him from a specialist mental health team, but they never responded.
Black Country Healthcare NHS Foundation Trust said a report would be submitted to the coroner in due course.
The Black Country Integrated Care Commission confirmed there was a 48-page report into the incident.
The BBC understands that Mr Wall had several referrals over a period of time, including one from Sandwell General Hospital.
The August 2023 referral was refused by Emergency Mental Health Services.
A further referral occurred in October of the same year and the on-call team was contacted in January 2024, but no risk was identified.
The Black Country coroner confirmed a pathologist had given Mr Wall's cause of death as organ failure due to lack of oxygen supply.
He also said chronic alcohol abuse and depression were contributing factors.
Black Country Healthcare NHS Foundation Trust said: 'Our thoughts are with Mr Wall's family following his tragic death.
“We are currently conducting a detailed investigation into this incident and a report containing potentially relevant findings will be submitted to the coroner and the Black National Comprehensive Care Commission in due course.”
The BBC has learned that the Care Quality Commission (CQC) is investigating problems at Walsall's Dorothy Pattison Hospital, which also cares for mental health patients.
A staff governor recently resigned after the Black Country Trust suffered one of the worst deteriorations in NHS staff surveys across England.
image captionThe Care Quality Commission is investigating Dorothy Pattison Hospital in Walsall, which provides inpatient adult mental health care
The health trust said it would continue to work with the CQC to support information requests and service visits.
It also said that improvements needed to be made and that it had worked with staff to develop plans to improve their experience, including around health and wellbeing.
Management added that it continues to strengthen relationships with consultants following a number of successful meetings.
The chair of the medical advisory committee said: “Positive progress has been made and we continue to meet regularly with the board.”
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