'Opportunities missed' to reduce risk of Jersey man taking his own life

Opportunities to intervene to reduce the risk of a Jersey man taking his own life were missed, an inquest has concluded.

Daniel Cram, 25, died on 2 December 2024 at his family home in St Saviour.

He attended a GP appointment on 22 November 2024 because of concerns around his mental health, working to live, and a serious ear infection, which was preventing him from his love of surfing and skateboarding.

However, in messages sent to family and friends and in posts on social media, he said he felt his mental health history was ignored, and that the locum doctor chalked it up to needing to grow up.

That GP, Dr Andrew Summers, told the inquest that he wasn't told of his mental health concerns, saying the approach to the consultation would have been very different if he was aware.

Daniel's mum, Louise, then phoned the GP practice back to say she wasn't happy with the outcome, and to ask for another appointment.

An appointment with another GP was then organised for the following day, which Ms Cram attended in the room with her son.

That GP, Sean Ryan, then got in touch with the Crisis Assessment Team because of extreme concerns about his suicide risk, and told the inquest that he felt strongly that Daniel should have been seen by a mental health team urgently.

However, during a phone call, the assessor downgraded the risk to 'routine', saying Daniel seemed 'quite relaxed', expressed regret about a previous attempt on his life, and that he was positive about the plan for physical treatment on his ear.

Despite his concerns, the GP, and Daniel, agreed to an appointment four days later, but Daniel then didn't attend.

Several experts - including the manager of the Crisis and Assessment Team at the time - told the inquest they would have graded Daniel's case as urgent, meaning he would have been seen within 72 hours, and possibly the same day.

After failing to attend, six phone calls were made to Daniel over the next five days, which went unanswered.

Plans were then discussed to cold-call Daniel's house, but that was pushed back, and didn't happen before Daniel died.

Ms Cram said an appalling lack of basic attention to the facts presented led to Daniel's unnecessary death.

She added that Daniel was trying to get help, but he was let down by the very people who should have helped him.

In concluding the inquest, Coroner Matthew Berry said the decision to downgrade the risk to routine was 'not correct'.

He also said that not speaking to Daniel's mum about his well-being was also an opportunity missed, as was not cold-calling Daniel earlier after his missed appointment with the mental health team on 27 November.

He added that it was also a missed opportunity not to make Daniel's GP aware that he missed that appointment, so he could ask him about it when he saw him again on 28 November.

The coroner decided against issuing a Prevention of Future Death Report because of the steps taken by Health and Social Care to make changes following Daniel's death.

That includes giving further advice and direction to the Crisis and Assessment Team as to how to escalate and follow up when people fail to attend appointments, improving communication with families, and improving record-keeping.

Speaking after the hearing, Daniel's friend Eduardo Da Rocha told Channel 103 lessons must be learned:

"We don't want to sit here and blame people. This is about remembering Danny, learning lessons, and doing everything possible to prevent other families having to endure the heartbreak that ours has experienced.

"Jersey loses approximately a dozen Islanders every year to suicide. This is a higher than average rate of suicide compared to the UK. For everyone death by suicide, dozens and dozens of family members, friends, colleagues, and communities are devastated.

"In response to Danny's tragic and unnecessary death, the Danny Cram Foundation was set up by the young people of Jersey who could no longer sit back and accept the lack of help. The message is a poignant and important story can be learned."

Eduardo had this message for other people struggling with their mental health:

"Please don't suffer in silence. Speak to someone you trust, you love. Contact your GP, reach out to friends and family, or even just anyone that you truly feel comfortable talking to."

In a statement, Andy Weir, Managing Director for Health and Care Jersey Services, said:

"On behalf of Heath & Care Jersey, I would like to again offer my deepest sympathies to Mr Cram’s family and loved ones. Any loss of life in these circumstances is a terrible tragedy.

"We have accepted the findings of the Serious Incident Review and the external psychiatric report, and continue to work to improve and strengthen our services."

Mental Health support services in Jersey:

• 24/7 Adult Mental Health Crisis Line: 01534 445290
• Listening Lounge on Charles Street, St Helier: 01534 866793
• Mind Jersey on Seale Street, St Helier: 07829 933929
• The Samaritans: 116 123 / 01534 116123
• Jersey Talking Therapies: Self-refer here.
• Youth Enquiry Service (YES): 01534 280530