'One-of-a-kind' carer died after mental health referral downgraded
- Credit: Danielle Booden
A "gentle and kind" carer died after his urgent mental health referral was downgraded from 72 hours to a month, an inquest has heard.
Louis Peter Crisp was found dead at his Lowestoft home in Stevens Street in June last year after concerns had been raised when he failed to turn up for work.
The 27-year-old, who had been a carer at Estherene House in Lowestoft, had been referred to the Norfolk and Suffolk NHS Foundation Trust's mental health services team by his GP as an urgent referral, which was then downgraded without explanation, the inquest at Suffolk Coroner's Court in Ipswich heard on Thursday, June 16.
His mother Kathryn Churchill said: "He was a very caring person and a very gentle and kind soul.
"He loved a type of Korean martial art called Kuk Sool Won and was very good at it.
"He had been doing it for about three years and was a few weeks away from doing his black belt grading, which the club awarded him posthumously.
"When he started working at Estherene House he ended up getting quite a close-knit group of friends who all looked out for each other."
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Mr Crisp began working at the care home, where his grandmother was a resident, shortly before the pandemic began.
Ms Churchill said: "He became a carer and was really good at it, and meant I got daily updates on my mother when I couldn't see her during lockdown.
"It is an extremely difficult job that demands a particular person to do it and it is grossly under paid for what they have to do.
"My own opinion is that the government's statutory staffing levels are inadequate.
"About three months before he died he was made a care coordinator so had to help train up new starters and he found it quite stressful and sometimes felt ignored."
The inquest heard also heard from a number of staff members at Estherene House, including manager Valerie Holland who said the home, which cares for up to 36 people, is always "overstaffed" based on the hours each resident requires according to their care plan.
She also hailed Mr Crisp as an "excellent worker."
Colleague and friend Morgan Curtis said: "He would always sit and talk to the residents, and visit the ones who were bed-bound, which was really nice to see.
"I don't think one carer or resident could say a bad word about him."
Another colleague and friend Chelsea Gallagher added: "He lit up the room and was probably one of the best people I've ever met."
Area coroner Jacqueline Devonish concluded Mr Crisp, who had a "long history of anxiety and depression" died as a result of suicide, adding the downgrading of his referral was an individual error, rather than a Trust policy.
She said: "He went to his GP who said he needed an urgent referral. She couldn't refer him to the crisis team because that's not how he presented and she did all she could do, which was make a 72-hour referral.
"That was downgraded to routine and a telephone appointment had been offered in a month's time.
"That process failed him because it was done without any communication with his GP. If there had been, that decision may have been reviewed.
"We don't know what happened with the mental health services' triage section but we have been told there have been learning as a result of his death."
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