Coroner criticises mental health trusts over Leyton man’s body dysmorphia suicide

A charity worker took his own life after mental health services discharged him without a “robust” risk assessment, an inquest found.

Conrad Colson, 34, died at his home in Fletcher Lane, Leyton, on March 2 last year, having been “plagued by body image problems” since he was at school.

Mr Colson’s “severe and enduring” condition, known as body dysmorphic disorder (BDD), meant he could become overwhelmingly anxious about the skin on his chin.

Following a suicide attempt in February 2020, the 34-year-old was under the care of a mental health team in North East London, as well as a specialist team in South London.

Before his death, he also spent thousands of pounds trying to fix his skin issues at private clinics in Harley Street, including the Dr Tatiana Clinic, which only worsened his anxiety.

In an inquest which concluded this week, coroner Nadia Persaud found mental health trust North East London Foundation Trust (NEFLT) failed to carry out a “careful and detailed assessment of risk” before discharging Conrad in November 2021.

Earlier that year, a “highly specialised” team at South London and Maudsley NHS Foundation Trust had also discharged Mr Colson after 20 sessions.

The coroner noted that both trusts chose to discharge him despite a suicide attempt only a year earlier and the “real risk of relapse”.

She added: “There should have been consideration of whether the ending of this highly specialised therapy might have led to foreseeable hopelessness.”

A plan prepared at Mr Colson’s discharge from the South London clinic, by clinical psychologist Dr Robert Medcalf, said neither the doctor nor the patient felt further sessions were needed.

The doctor also wrote: “Suicide is always in the back of his mind and can be triggered by catching sight of his image. He does not want to die and thinks if he could overcome BDD he could have a good life.”

Ms Persaud said she would issue a preventing future deaths report to both NHS trusts and the Dr Tatiana clinic, which she found had failed to review whether he suffered from BDD before offering treatment.

The coroner said there was an “absence of liaison” between the trusts and a “lack of information sharing”.

She added: “I have been informed before by the trusts that they are going to take action in relation to risk assessment and risk management, yet time and time again risk assessments are a key concern at inquests.”

During the inquest, it emerged that the private skin clinic had only asked Conrad to fill out a “simple checklist questionnaire” about his mental health before treatment.

The inquest was also delayed after the clinic and key witness, consultant surgeon Massimiliano Cariati, had to be recalled for further questions after failing to mention several emails Conrad sent raising concerns about his appearance after paying for laser and microneedle treatment.

In an email in April 2021 – only shared on the second day – he told the clinic: “I feel like the area looks worse than ever and is more dented/discoloured…. As much as I try not to let it, it is massively hampering my self-confidence.”

The coroner found that the clinic should have carefully reassessed him after he began raising concerns about his appearance despite his skin issues being, in Dr Cariati’s words, “objectively not obvious” to an outside observer.

Despite these failings, Ms Persaud found that the clinic did not contribute to his death “on the balance of probabilities”.

She added: “It is not possible to say what the outcome would have been if a careful screening for BDD took place in March to May 2021.”

In a statement issued after the inquest, a spokesperson for the Dr Tatiana Clinic said: “We have seen the coroner’s findings in respect of our BDD processes and note that, whilst she was satisfied with the policy and training in place, there is further work to embed the processes.

“As an organisation we strive to learn and develop our processes and are grateful to the coroner for the opportunity to clarify with her the further and ongoing learning.

“We would like to offer our sincere condolences to Conrad’s friends and family following his death.”

A spokesperson for SLAM said: “We would like to offer our deepest condolences once again to Conrad’s family and friends.

“Everyone involved in Conrad’s care at the trust was greatly saddened to hear of his passing.

“The Centre for Anxiety Disorders and Trauma has taken action to address its discharge policy to more robustly assist a patient’s ongoing care and support at the time when they are leaving our services.

“The trust acknowledges the coroner’s recommendations made at the hearing and will respond to those within the required timeframe.”

A spokesperson for NELFT said: “We’d like to express our most heartfelt condolences to Conrad’s family, friends and loved ones at this very difficult time.

“We accept the shortcomings identified in Conrad’s care by the coroner and we are sincerely sorry for them.

“We will follow our internal processes to address areas of improvement, to make sure patients with body dysmorphia receive the specialist treatment they need.”

Click here for information and support about body dysmorphic disorder.

When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.

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Josh Mellor

Local Democracy Reporter