The Black Country Mental Health Trust is investigating a man’s suicide

A man’s death is being investigated by a mental health trust after it emerged crisis teams failed to take action despite multiple referrals.

Heron Wall, 49, took his own life in West Bromwich on February 18 this year.

In the months before his death, it emerged that doctors had asked specialist mental health teams to support him on several occasions, but they never did.

Black Country Healthcare NHS Foundation Trust said a report would be submitted to the coroner in due course.

The Black Country Integrated Care Board confirmed there was a 48-page report on the incident.

Several referrals were made for Mr Wall to work over a period of time, including some from Sandwell General Hospital, the BBC understands.

A referral in August 2023 was dismissed by emergency mental health services.

There was a further referral in October of the same year, then in January 2024 a watch team was contacted but found no risk.

The Black Country coroner confirmed that a pathologist had given Wall’s cause of death as organ failure caused by a lack of oxygen supply.

He also stated that chronic alcohol abuse and depression were contributing factors.

Black Country Healthcare NHS Foundation Trust said: “Our thoughts are with Mr Wall’s family following his tragic death.

“We are currently carrying out a detailed review of the incident and a report together with any potential associated learning will be submitted to the coroner and the Black Country Integrated Care Board in due course.”

The BBC has learned that the Care Quality Commission (CQC) is investigating problems at Walsall’s Dorothy Pattison Hospital, which also deals with mental health patients.

A staff governor recently resigned after the Black Country trust suffered one of the worst deteriorations in its NHS staff survey of any part of England.

The health trust said it continued to work with the CQC to support any requests for information or service visits.

It also said it needed to improve and had developed plans in partnership with staff to improve their experience, including around health and wellbeing.

Management continues to strengthen the relationship with consultants after a series of successful meetings, he added.

The chairman of the Medical Advisory Committee said: “Positive progress has been made and we continue to meet regularly with the board.”