Source · Prevention of Future Deaths

Peter Lawrence

Ref: 2019-0245 Date: 1 Jul 2019 Coroner: Zafar Siddique Area: Black Country Responses identified: 1 / 2 View PDF

Inadequate joint multi-disciplinary care planning and excessive reliance on a tribunal decision led to delayed responses to relapse indicators and insufficient follow-up for a patient with a history of disengagement.

Date 1 Jul 2019

56-day deadline 27 Aug 2019

Responses identified 1 of 2

Mental Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. Evidence emerged during the inquest that a number of contributory factors played a role in his death as highlighted as follows:

2. There was a lack of a joint multi-disciplinary/agency care plan (between Local authority and Mental Health Trust) which could have resulted in delays in a timely response to known relapse indicators.

3. A more assertive approach with consistency of care coordinator for a patient with a history of disengagement and relapse could possibly have been implemented reducing the likelihood of disengagement with services and promoted necessary concordance with medication.

4. A decision to admit to hospital under the mental health act following concerns being raised about self-care and disengagement could potentially have followed a coordinated MDT review and mental health act assessment and prevented deterioration in his mental health.

5. When PL was successful at the mental health tribunal and was discharged from Section 3 following his last admission to hospital in October 2017 against the view of the multidisciplinary team. The agencies involved placed too much reliance on this decision and follow up engagement and monitoring with PL reduced becoming inadequate.

Responses

1 respondent

Dudley and Walsall Mental Health NHS Trust NHS / Health Body

13 Sep 2019 PDF

Action Planned

The Trust, in conjunction with Walsall Council, has formulated a joint action plan to ensure that policies and procedures relating to multidisciplinary/agency care plans and risk assessments meet the needs of community patients with complex needs. (AI summary)

View full response

Dear Mr Siddique

Ref: Peter Lawrence Inquest 3 June 2019 Regulation 28: Report To Prevent Future Deaths – Dudley and Walsall Mental Health Partnership NHS Trust (“The Trust”) Response.

I write further to the inquest held in relation to Peter Lawrence and your Regulation 28 Report to the Trust dated 1 July 2019. I understand that the confirmed deadline for the Trust’s response is Monday 16 September 2019.

In addition to the work carried out to implement the recommendations arising from the Trust’s RCA Investigation Report, upon which you heard oral evidence at the inquest, both the Trust and Walsall Council have been working closely together in order to formulate an approach to address the concerns contained within your Regulation 28 Report.

I would, first of all, like to express my sincere condolences to Peter’s family for their loss and to assure them that the Trust working in conjunction with the Local Authority are fully committed to providing excellent mental health care to the service users of Dudley and Walsall in a way which is safe and effective for patients and their families.

The Trust has in conjunction with Walsall Council formulated a further joint action plan to ensure that policies and procedures relating to multidisciplinary/agency care plans and risk assessments meet the needs of community patients with complex needs and that a multi- agency working approach is reinforced going forward.

I do hope that the proposed actions detailed in the attached plan address the areas of concern outlined within your Regulation 28 Report to the Trust. However should you need any further clarity or explanation regarding the same please do not hesitate to contact me.

Report sections

Investigation and inquest

On the 20 February 2019, I commenced an investigation into the death of Mr Peter Lawrence (PL). The investigation concluded at the end of the inquest on 3 June 2019. The conclusion of the inquest was an open conclusion.

The cause of death was:

1a Total Spinal Cord Transactions b Traumatic Fracture And Dislocations Of Vertebral Column c Traumatic Bilateral Haemopneumothorax

Circumstances of the death

i) Mr Lawrence was a 48 year old gentleman who had been diagnosed with paranoid schizophrenia. ii) He had over 19 previous admissions to Psychiatric Hospitals when he was detained under the Mental Health Act. His last admission was at Dorothy Pattison Hospital on the 20 August 2017 to 26 October 2017. He successfully appealed against his detention to the mental health tribunal and was discharged from his section. During periods of relapse he was known to deposit faecal matter in his bath. iii) Attempts at follow up appointments were difficult and he disengaged from the service until 22 January 2018 when a joint home visit with the housing officer identified the poor state of his living environment. A care coordinator was also involved in trying to support him. iv) On 6 August 2018, he was found in the canal with an apparent attempt to self-harm. He was taken into Police custody and recalled to prison with no

[IL1: PROTECT] mental health act assessment taking place. v) He was released back into the community on 4 October 2018 and attempts were made to see him again. However he didn't allow entry to his flat and was still difficult to engage and meet. vi) At a joint home visit on the 22 January 2019, with his care coordinator and housing officer, it was noted that his flat was filthy with bird faeces and there was no electricity or gas. There was no bed and it appeared he slept on the floor with a sheet covered with a blanket. His bathroom was full of human faeces. vii) On the 8 February 2019, the deceased was found on the ground outside his flat having fallen from the balcony. He sadly died from the traumatic injuries sustained.

Action should be taken

[IL1: PROTECT]
1. Both agencies involved may wish to consider reviewing their approaches to multidisciplinary/agency care plans and risk assessments for community patients with these complex needs.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2019-0245
Date of report: 1 July 2019
Coroner: Zafar Siddique
Coroner area: Black Country

Responses identified

Responses identified 1 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Aug 2019.

Sent to

Walsall Mental Health Partnership

Walsall Metropolitan Borough Council

Part of a series

3 reports

2016-0314 0 responses identified

2023-0130 0 responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.