Norwich Evening News: Man “frustrated” at mental health delays took his own life after NHS 111 hung up on him

Dominic Gilbert of the Norwich Evening News reports:

A 32-year-old with Asperger’s and emotionally unstable personality disorder took his own life when NHS 111 call handlers hung up on him after months of “frustrations” with mental health services.

At the inquest into his death, John Worthington’s parents have said their son was “failed” for years in his search for help.

Norfolk Coroner’s Court heard how;

  • John had to wait almost five months for a mental health assessment
  • A GP criticised the delay from the “chronically underfunded” mental health services
  • John was told to call the NHS 111 service but they hung up on him when he struggled with a speech impediment.

By the summer of 2017 he had reached a crisis point and called NHS 111 four times in the early hours of June 6.

During the fourth call John made an attempt on his life after a pathways advisor terminated his call. Paramedics were dispatched and police gained entry to his flat at St Augustine’s Gate in Norwich.

John was resuscitated and taken to the intensive care unit at the Norfolk and Norwich Hospital (NNUH). But the brain injury he had sustained was so severe he did not survive, eventually passing away on August 11.

The electrician and former nightclub manager had spent two years trying to get help from mental health services, and saw his GP 29 times in a single year.

Before the radical redesign cuts, there were mental health link workers in GP’s surgeries.

Dr Jones told the court: “When he was referred we made it clear there was an underlying suicidal ideation. He told me a number of times when he was angry or annoyed he might feel like doing something.”

He added: “John was referred on December 19 and given an appointment on May 10. That is about a week shy of five months. There is no guarantee patients will be seen within 28 days but under ideal circumstances it would not be another four months for someone to be offered an appointment. The risks were made known and clearly stated on the referral.

“The fact is [NSFT] are saying they are chronically underfunded. It is my experience as a GP who has worked in two practices with a high prevalence of mental health issues it can be sometimes very difficult.”

James Forrest, charge nurse at the mental health liaison team at NNUH, met with John at A&E on December 21, 2016 after he had again threatened suicide.

“He described frustrations he had experienced trying to access mental health services for a two year period,” Mr Forrest told the court. “It was his experience of trying to access mental health support that led him to feeling suicidal.”

Five months. Shameful.

John was placed on a patient of concern list at the GP and given an admissions avoidance care plan, which recommended he call NHS 111 to avert the need for A&E attendance.

But facial ticks which accompanied John’s functional facial movement disorder meant he often struggled to speak.

On June 6 he called NHS 111 but was met with pathways advisors who “did not communicate effectively, professionally or with appropriate warmth”, according to a service delivery report from IC24.

During one call, according to transcripts seen by this newspaper, he told the call handler: “You’re terminating the call because you are not patient enough to listen to a speech impediment”.


A root cause analysis report of the incident from IC24 investigated four calls from John to NHS 111 between 2.12am and 2.53am.

“All of the calls received were difficult for all concerned,” the report said. “The patient was suffering with communication problems and was finding it hard to articulate.

“This caused the patient to become incredibly frustrated with all who dealt with his contacts. Unbeknown to the call handlers the deceased was known to mental health services and had been directed to call NHS 111 by the local crisis team.”

The IC24 report added: “NHS 111 were unaware of any existing mental health support plan for the patient. NHS 111 were unaware of the process for the mental health crisis team for patients to ring 111 before mental health intervention.”

After the inquest, John’s parents, Keith Murdoch and Samantha Harrowven, said their son was a “wonderful young fellow” who had been failed by mental health services.

“There were definite failings with the NHS 111 calls”, said Mrs Harrowven.

“The clinician on the phone said he was not known to them and there was no recognition he was at risk,” she said. “All through the call he was ranting on about mental health services failing him.”

She added: “Three years ago I called 999 saying I need my son sectioned. He was screaming down the phone saying he was going to kill himself.”

“He wanted answers on why he felt the way he did,” added Mr Murdoch. “Everything was so slow. Ultimately I do not think mental health teams did enough.”

John was described as a “selfless” and “much loved big character”.

“He was one of those people who was intelligently brilliant and superb with his hands,” said Mr Murdoch.

How many more appalling unnecessary deaths must Norfolk and Suffolk endure?

How can the Chair of Norfolk and Suffolk NHS Foundation Trust for the last four years of cuts and Board incompetence, investment banker Gary Page, honourably remain in his post?

When are the CCG’s going to fund mental health services properly? NSFT’s share of Norfolk’s NHS budget has fallen by 8.3 per cent since the CCG’s were established despite referrals rising 48 per cent. Over the same period, the CCG bureaucrats have awarded themselves huge pay rises and disgraced and unaccountable Patricia Hewitt has mysteriously become Chair of the latest cuts vehicle, the STP.

When is the shameful Board of NSFT going to begin genuine engagement with the bereaved, patients and carers rather than ending meetings early to avoid questioning?

And, of course, we have yet another narrative verdict because people with poor mental health cannot die of suicide in Norfolk.

This tragedy is featured in both the EDP and Norwich Evening News today.

High quality, investigative reporting is so important to our campaign. Buy a newspaper if you can. If not, click on the image below to read the full article on the Norwich Evening News website.


197 thoughts on “Norwich Evening News: Man “frustrated” at mental health delays took his own life after NHS 111 hung up on him”

  1. What is the point in ‘crisi teams’ ‘crisis lines’ AAT’s etc if people are just told to call NHS111, the samaritans (who themselves are overwhelmed by increased calls and loss of experienced volunteers due to changes in their fundamental philosophy regarding complete confidentiality and now have ‘safeguarding rules’ to follow). I’ve even had an idiot from an AAT tell me to ‘ask google’ for information on a diagnosis I didn’t have and was ridiculously inapropriate! People need real help at the time they need it, not to be passed or ‘signposted’ from pillar to post, until they become desperate enough to act on suicidal plans.Whilst this goverment is still in power, health, social care and the welfare stae will contiue to be ripped apart. The poor are getting pooer, the vulnerable are dying and many peoples lives are unstable and precarious (but unemployment is down – because most of it is hidden).

  2. We don’t really have a mental health service to save, we don’t have a service full stop. Someone needs to ask themselves why we don’t have one? Maybe we have aload of staff like the woman who impersonated a mental health Dr for years. The whole service needs looking it as its been letting people down  for years!

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