Source · Prevention of Future Deaths

Hadley Savory

Ref: 2022-0402 Date: 11 Aug 2021 Coroner: Ian Brownhill Area: North East Kent Responses identified: 0 / 3 View PDF

There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental health, substance misuse, social care, and physical health needs.

Date 11 Aug 2021
56-day deadline 6 Oct 2021
Responses identified 0 of 3
Alcohol, drug and medication related deaths

Coroner's concerns

AI summary
There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental health, substance misuse, social care, and physical health needs.
View full coroner's concerns
(1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs;

Report sections

Investigation and inquest
Hadley John Savory was found dead at his home address in Margate on 13 December 2019. An investigation into his death was commenced. The investigation concluded at the end of the inquest on 11 August 2021. My conclusion was that his death was drug related, in addition, a short narrative conclusion was given as explained further under section 4 below.
Circumstances of the death
Hadley John Savory was discharged from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. A multi-agency meeting did not take place prior his discharge from hospital. The plan for Mr Savory’s care, support and treatment in respect of his substance misuse, physical health, mental health and social care needs is unclear. Mr Savory’s presentation declined in the community. Safeguarding referrals were made but no multi agency meetings were convened pursuant to safeguarding duties under the Care Act or as per the Kent and Medway Multi-Agency Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour. Police made entry into Mr Savory’s home address on 13 December 2019, he was found to be deceased. Toxicological evidence indicated that Mr Savory had taken a lethal dose of methadone. There was no evidence that Mr Savory had intended to take an overdose.
Copies sent to
In addition, I have sent this toIndependent Chair of the Kent and Medway Safeguarding Adults BoardYou may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. SignatureIan BrownhillAssistant Coroner North East Kent11 August 2021

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Report details

Reference
2022-0402
Date of report
11 August 2021
Coroner
Ian Brownhill
Coroner area
North East Kent

Responses identified

Responses identified 0 of 3
3 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Oct 2021.

Sent to

East Kent Hospital University NHS Foundation Trust
Kent and Medway NHS and Social Care Partnership Trust
Forward Trust

Part of a series

2 reports
2021-0270 All responses identified

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