Callan Atkins

I am Roland Wooderson Area Coroner for the coroner area of Gloucestershire

On 23 May 2023 I commenced an investigation into the death of CALLAN NORMAN COLLINS ATKINS. The investigation concluded at the end of the inquest on 26 June 2025. The conclusion of the inquest was as set out below.

On 18 May 2023 Callan was found hanging from a rafter at his home address. He was confirmed dead at the scene by a paramedic. The Police confirmed that there was no third-party involvement. He had recently undergone neurosurgery for epilepsy and believed that this had worsened his medical condition. His family considered that, at the time of his death, he was in a negative mindset and was constantly thinking about ending his life. It was clear that Callan took his own life and intended to so do. At the time of his death Callan was receiving assistance from clinicians in the NHS Mental Health Intermediate Care Team. There was a telephone appointment held between a member of that team and the deceased on 17 May 2023. Thereafter, an arrangement was made for a clinician from the mental health Crisis team to contact Callan on 18 May 2023 to arrange a face-to-face visit. A subsequent enquiry concluded that there was an opportunity missed to conduct a face-to-face assessment on 17 May 2023 between Callan and a member of the Crisis team. This would have been the ideal position. This was not possible due to the Crisis team’s high clinical workload on 17 May 2023 albeit the Crisis team could have explored whether clinical agency staff were available to supplement the staff on 17 May 2023. However, the evidence did not disclose that there was any possible or probable contribution to Callan’s death flowing from the Crisis team not seeing Callan on 17 May 2023.

During the course of the inquest the evidence revealed matters giving rise to concern. 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.  – That staff capacity of the mental health crisis team of the Gloucestershire Health and Care NHS Foundation Trust will dictate whether a patient is assessed on the same day when their clinical needs demand they are. That the Trust will not make any enquiries as to additional resources when their local Crisis team has no capacity.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.