Tony Duncan: Prevention of future deaths report

1.  The Medical Director of the South London and Maudsley NHS
Foundation Trust 

I am Alison Hewitt, HM Senior Coroner for the City of London.

I make this report under paragraph 7 of Schedule 5 to the Coroners and  Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

I commenced an investigation into the death of Tony Montana Duncan.  
The inquest was concluded on the 8^th October 2025 when I found that the  medical cause of death was:   
Ia Submersion 

and my conclusion as to the death was that: 
The Deceased died as a result of his own deliberate act when his state of  mind was adversely affected by acute symptoms of his previously  diagnosed mental illness which had probably resulted from a period of  non-compliance with medication prescribed to manage those symptoms.  The Deceased’s death was more than minimally contributed to by his  receiving no treatment or support from mental health services following  his assessment by the psychiatric liaison team at King’s College Hospital’s Emergency Department on the 21st June 2024. 

Tony Duncan suffered long-term mental ill health, with a diagnosis of  personality disorder, the symptoms of which were usually managed by  prescribed medication. In May 2024, he was exhibiting acute symptoms of
his underlying condition, and on the 21st June 2024, he presented to his General Practitioner complaining of persisting headache, an acute  deterioration of his mental health on a background of non-compliance  over previous weeks with his prescribed medication, and suicidal  ideation, expressing a plan to jump [REDACTED] if he did not 
receive help. 

The Deceased was sent, by his General Practitioner, to the Accident and  Emergency Department of King’s College Hospital, with a referral letter  requesting assessment of his mental state, possible admission, and 
medication review. The Deceased was seen later that day by the  psychiatric liaison team at the hospital, whose services were provided by  the South London and Maudsley NHS Foundation Trust. Following  assessment, it was decided that his presentation resulted principally from  his social circumstances rather than his mental illness, and he was  discharged back to the care of his General Practitioner. The assessment  took no account of the Deceased’s reported plan to end his life by jumping from a bridge if he did not receive clinical treatment or support. 

Towards the end of June 2024, the Deceased left his home address, with a  selection of his belongings, in a distressed state. At about 03.00 hours on 
the 4th July 2024, he jumped from [REDACTED] into the River Thames 
below. He was carried quickly towards [REDACTED]  by the current and it
is likely that he died within a short time of entering the water. The Deceased’s body was subsequently found on the 7th July 2024, near to  Oyster Wharf mudflats, and his death was formally pronounced at 11.56  hours on that day. 

The evidence I have gathered to date reveals matters giving rise to  concern. There were concerns about the manner in which the South  London and Maudsley NHS Foundation Trust’s Single Point of Access  service was operating in the summer of 2024, but I heard evidence which satisfied me that those concerns have since been addressed.  

However, the matters of concern set out below persist and, in my opinion, there is a risk that future deaths could occur unless action is taken. In the  circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows:  
1.  The Deceased presented to the South London and Maudsley NHS 
Foundation Trust’s psychiatric liaison team which was operating  within the Accident and Emergency Department of King’s College Hospital, with a referral letter from his General Practitioner which sought possible admission and medication review. The Deceased  was known to the Trust and he had been the subject of a  safeguarding referral and a self-referral shortly before his  attendance at the hospital. From the information available to the  psychiatric liaison team, it was apparent that: 

(i)       The Deceased had a chronic and persisting mental health  condition which was usually controlled by medication but 
which, when not controlled, could give rise to suicidal  ideation; he had previously been helped by periods of  detention / voluntary admission to hospital, 

(ii)      By May 2024, there was evidence that he was suffering an 
acute deterioration in his mental health which he  subsequently reported was because he had not been  properly compliant with his prescribed medication for a  number of weeks, and 

(iii)     The Deceased recognised the deterioration in his mental 
health, that he was suffering specific suicidal ideation 
relating to jumping from London Bridge, and that he needed  help from mental health services, including by voluntary  admission to hospital; he sought help by making a self- referral to the Trust via the Single Point of Access service and by attending his GP and the hospital. 

2.  When the Deceased attended the hospital, the Accident and  Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social  stressors rather than mental illness; she was not concerned about  the risk of suicide because he had no plan or intent; and she  referred the Deceased to the homelessness team and discharged  him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or  escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding.  Despite there being a recognised risk to self and to others, both of  which the Deceased himself said he could not control, there is no  evidence of any risk assessment documentation being completed. 

3.  The Deceased was subsequently seen in the Accident and  Emergency Department by a Social Worker from the homelessness 
team. The Deceased insisted that he was not homeless and that he  had attended the hospital for help with his mental health, without  which he would jump from London Bridge. The Social Worker immediately passed this information to members of the psychiatric  liaison team who he found, together, in their office. Subsequently,  whilst still in the department, the Deceased became agitated and  abusive, which behaviour was a recognised aspect of his behaviour when he was unwell. It seems he later left the department and/or  was escorted out as he was being abusive; the records show that at  least one member of the psychiatric liaison team was aware of this  development but took no action to prevent the Deceased from  leaving or to encourage him to stay in order to re-assess him, nor to alert the Crisis and/or Home Treatment teams, the GP, or the  Deceased’s family as to the situation. 

4.  Following the report of the Deceased’s death, South London and  Maudsley NHS Foundation Trust’s own review highlighted various
concerns about the operation of its Single Point of Access service  but neither that review, nor the evidence provided to the inquest  from the Consultant Psychiatrist who was responsible for the psychiatric liaison team in King’s College Hospital, identified any  concerns about the management of the Deceased by the psychiatric  liaison team on the 4^th July 2024. This may suggest that there were systemic as well as operational factors which led to the Deceased  not receiving the help and support he needed on the 4^th July 2024.

In my opinion action should be taken to prevent future deaths by  addressing the concerns set out above and I believe your organisation have the power to take such action.  

You are under a duty to respond to this report within 56 days of the date of this report, namely by the 10^th December 2025.  I, as coroner, may  extend the period. 

Your response must contain details of action taken or proposed to be  taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 

I have sent a copy of my report to the Chief Coroner and to the Interested Persons and other organisations listed below which may find it useful or  of interest: 

The Mother of Tony Duncan, and 
King’s College Hospital NHS Foundation Trust. 

I am also under a duty to send the Chief Coroner a copy of your response.
I may also send a copy of your response to any other person who I believe may find it useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he  believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the  publication of your response by the Chief Coroner.