Tributes paid to David Rutty, found dead at home in Hove

David Rutty was found dead at his home in Clarendon Villas, Hove, on Monday, November 25 last year.

A neighbour who had become worried about the 46 year-old had gone to check on him and found David slumped with a ligature around his neck. An ambulance was called but paramedics confirmed David had died at 3.12pm.

At the inquest into his death held last Monday, September 14, the court at the Jury’s Inn hotel in Stroudley Road, Brighton, heard David had suffered from epilepsy and agoraphobia and had endured “a lot of issues in his life he struggled to cope with”.

David’s good friend Susi Neale told the court: “David moved to Brighton about 20 years ago and in 2007 he made a serious suicide attempt.

“He knew enough about what to say to avoid being sectioned but I’m shocked an intervention was not done at this stage.

“I went to see him in September last year and he was unrecognisable. He had lost a lot of weight and lost his sense of humour and his wit.

“I was very worried by how much my friend had changed.”

In October last year David began having weekly meetings with a lead practitioner from the Assessment and Treatment Service (ATS), described as the “entry point” to more specialist mental health services by Sussex Partnership NHS Foundation Trust.

David was reported to be low in mood with suicidal thoughts and was considered to be at “medium to high risk” of self harm.

He was already on a variety of medication, including benzodiazepine, and towards the end of last year David was suffering with physical health problems and drowsiness and had lost a lot of weight.

The court heard David’s GP had referred him to the ATS and requested a medication review at the start of October, but an appointment for a review was not arranged until mid November for a date in January.

Assistant coroner Catharine Palmer said: “The doctor had specifically requested a medical review, as she had reached the maximum she could prescribe him.

“Why is it that although a GP was saying this, it was downgraded as not important?”

The coroner also questioned why no care plan had ever been written for David by the ATS mental health team.

David’s first lead practitioner, Madeleine Cartmell, told the court that in her weekly meetings with him they talked about other methods of support.

She said: “He was willing to engage with our community teams and he wanted help. We were looking at goals and spoke about the Group Therapy Service at Mill View Hospital.

“We spoke a lot about a plan but it was not written down, and that should have been done.”

Ms Cartmell referred David to the mental health Crisis Team at the end of October but said he was not accepted for further treatment or a hospital admission, and was referred back to the ATS.

The coroner said David was “clearly distressed” and described the situation he was in as a “vicious circle he had no real control over”.

On November 1, David asked to be admitted to The Haven at Mill View Hospital, a 24-hour mental health crisis facility. He was seen by a nurse but not admitted to hospital.

Ms Cartmell was leaving the service in November and two handover sessions were arranged to introduce David to his new lead practitioner, Sian Smith.

Susi Neale, who had asked to be kept informed in all matters regarding David’s care, told the court that by the start of November she was very worried about her friend.

She said: “I spoke to him on the phone and I could hear he was working himself up to harming himself.

“Sian took over from Maddie as his lead practitioner and this discontinuity at such a critical time had a real impact on David.

“I understand public services are underfunded and staff are trying to do their best. However I can’t help but feel that they failed him.”

Four days before he died, David did not attend his meeting with his new lead practitioner, Ms Smith, on Thursday, November 21.

Ms Smith told the court: “David preferred to communicate by text and he said he’d had a horrible week and had flu symptoms. It was interpreted as being more of a physical problem.”

The coroner questioned why this was the case and said: “But it could have been a mix of both. This was on the Friday and nothing was done until the Monday.”

The court heard that Susi Neale was not contacted by the trust about David’s sickness and him not attending his ATS meeting, even though she had asked to be “included in all matters concerned”. Ms Smith acknowledged that “this was missed”.

The Sussex Partnership NHS Foundation Trust carried out an investigation into David’s care following his death.

Mark Melling, professional lead nurse at the trust who wrote the investigation report, said: “There is still progress to be made.

“I would like to have seen a care plan but when I saw David had not had a medication review I was not immediately concerned. It was important but not critical.

“I think what is positive is that staff all saw him as a person.”

In her conclusion, the coroner urged the trust to reflect on its ways of working and to improve communication.

She said: “There was no written care plan in place and that should have happened. Talking about it is not enough.

“The lack of involvement with Ms Neale is troubling. The last thing she said was ‘why didn’t someone ring me’, and that resonates.

“What I cannot say with any certainty is whether David would still have taken the action he did, even if all the issues we have identified had been addressed.”

Ms Palmer recorded that David took his own life. She gave his cause of death as hanging, with anxiety and depression as contributing factors.

She said: “With his mental health as it was I don’t think it was a cry for help.

“Ms Neale, even when you had your own problems you supported him and your care was outstanding. You did what you could for him and could not have done any more.”

During his life David had played in bands and was a DJ who loved techno and psytrance music.

Susi described him as “intelligent, creative and hilarious”.

Speaking after the inquest, she paid tribute to her friend and said: “Many memories are deeply held with love, by me and many who knew David.

“His character and personality are impossible to forget and love.

“The only comfort that his tragic death brings is that he is no longer suffering. He’s at peace making lots of noise as only he knows how.

“There is also solace in knowing that someone so special will never be forgotten.

“Someone as unique as David will never be forgotten. He will remain in our thoughts and hearts forever.”