Southern Health has said it is working to improve the links between mental health support and other services in the wake of inquests into the deaths of Alex Sartain and Councillor James Nash.

Mr Sartain shot and subsequently attacked Cllr Nash during a confrontation at the latter’s home on August 5, 2020, before dying in a road traffic collision later that day. During the inquest, it was revealed that communication issues between the mental health team and the Adelaide Medical Centre meant that concerns over Mr Sartain’s mental state were not picked up on.

Southern Health said it has since carried out a review into its interactions with him, and said it is constantly working “to ensure people get the most joined up mental health care possible”.

During the inquest into the death of Cllr Nash, the coroner’s court heard that after being sectioned under the Mental Health Act in 2019, Mr Sartain had been discharged from a hospital in November. He was then passed to the community mental health team, who cared for him for a time.

However, in April, they discharged Mr Sartain without having seen him, saying that they were “unable to contact him”. A letter was sent to the Adelaide Medical Centre, his GP, but was filed by a member of the administrative staff and was never seen by a doctor.

In June 2020, John Sartain, Alex’s father, was visited by a mental health visitor, but they did not see Alex. In a Radio Four interview, he said he was told that his son’s deteriorating mental state was “ sort [of] about normal.”

John Sartain also called the Adelaide Medical Centre, where a receptionist advised “there was nothing we [the surgery] can do.” A subsequent review found this was inappropriate advice, but the inquest noted that even if Alex Sartain had been seen by a doctor, there is no guarantee he would have been sectioned again.

In a statement, Dr Mayura Deshpande, Deputy Chief Medical Officer for Southern Health NHS Foundation Trust, said: “We express our condolences to the families of Mr Nash and Mr Sartain. Our thoughts are with them at this most distressing and difficult time.

“Homicides involving people with mental health problems are incredibly rare and we take any such tragic incident extremely seriously.

“Although Mr Sartain was not using our services when these events took place, we have carefully reviewed the support we provided in the months prior to the incident.

“The local NHS is constantly working to improve the links between mental health, NHS 111 and GP services to ensure people get the most joined up mental health care possible.”

The Adelaide Medical Centre has since undergone a change of management, with new partners taking over the practice. The inquest was told that the new partnership had introduced several robust systems, some of which are designed to prevent the repeat of incidents like this. In particular, discharge letters are now always seen by a doctor.

A spokesperson said that the practice was not able to comment at this time, but would do so in due course.