Viktor Scott-Brown's suicide 'could have been avoided'

The parents of Viktor Scott-Brown say he was let down ‘on many levels’ by Tees, Esk and Wear Valley Trust before he was found hanging by his mother in December 2018.

He had suffered from anxiety and depression for several years, but crucially, following a diagnosis of bipolar mood disorder the month before his death, his medication was changed and he was prescribed Lamotrigine.

The drug is known to have a possible side effect of potentially increasing thoughts of self-harm and suicide, but Viktor, who was 23, was not given the trust’s leaflet on the drug, or warned of the dangers.

The inquest at Crook Civic Centre heard Viktor, of Johnson Terrace, Annfield Plain, kept a meticulous mood diary, which show the deterioration in his mental health in the weeks after it was prescribed.

Assistant Coroner for County Durham Oliver Longstaff recorded a verdict of suicide, as well as a narrative verdict in which he said: “He had recently been prescribed Lamotrigine but had not been warned that use of that medication carries a risk of causing thoughts of self-harm or suicide, and his taking of that medication was not monitored accordingly.

“Had he been informed of that risk, he would have sought medical assistance when he began to experience thoughts of self-harm and suicide, and it is unlikely he would have taken his life when he did.”

During the inquest it emerged there was no risk assessment, or care plan produced for Viktor, and that a serious care review carried out after his death contained inaccuracies the family believe are designed to downplay the trust’s involvement in Viktor’s death.

In a statement released after the hearing, Viktor’s parents, Nick and Claire Scott, said: “It is of equal insult to our son’s memory that a key witness refused to attend court at the eleventh hour, citing stress and being overwhelmed as her reason.

“The family will now pursue the individuals involved in Viktor’s care vigorously and using all available avenues.

“We would hope that the Trust would wish to learn from their mistakes with Viktor, to help other vulnerable young people.

“It is clear however that their cavalier attitude towards completion of the most basic clinical and administration tasks leaves those in need of help in a very vulnerable position indeed.”

The family has thanked the coroner for the verdict, and the time taken to examine the circumstances of Viktor’s death.

They added: “Viktor was much loved, and a central part of our family.

“He was a caring, polite, charming and humorous young man who was universally liked by those who met him.

“The coroner’s verdict confirms the family’s belief that Viktor was let down by those who were supposed to be caring for him.

“We have witnessed in court that our son was let down on many levels, by many employees of Tees, Esk and Wear Valley Trust.”

The cause of death was recorded as hanging and Durham Constabulary has confirmed there were no suspicious circumstances.

Jennifer Illingworth, Tees, Esk and Wear Valleys NHS Foundation Trust’s director of operations in Durham and Darlington, said: “My thoughts are with Viktor’s family and friends at this difficult time.

“We are incredibly sorry that the care Viktor received was not of the highest standard.

“We undertook a comprehensive review of Viktor’s care and have taken action to address the findings from this.

“We will now take some time to look at the coroner’s recommendations and make sure we embed the learning from these as well as those from our own review.

“We will continue to be in contact with Viktor’s family to help resolve their ongoing concerns.”