Robin Richards

On 03/07/2015 commenced an investigation into the death of Robin Damien Richards, aged 33 years old The investigation concluded at the end of the inquest on 09 March 2018. The conclusion of the inquest was Robin deliberately chose to suspend himself by a belt and on balance, at that time, he intended that the outcome be fatal. The Jury concluded that issues contributing to Robin's death included: communication; training, information sharing; discharge planning; care planning and risk assessment: At about 19.50 on 29th June 2015 Robin Richards was found suspended by his belt on the staircase at Highbridge Court; Burnham on Sea_ He was unconscious. Emergency care was administered and he was taken to Weston General Hospital where he died at 09.20 on 3rd July 2015.Cause of death was recorded as severe hypoxic brain injury secondary to hanging:

Mr Richards has a long history of contact with mental health services_ He was first assessed aged 16 years. Mr Richards had diagnoses of Asperger's Syndrome, Attention Deficit Hyperactivity Disorder (ADHD) and a learning disability. In addition he had fluctuating depressive, anxious and psychotic symptoms_ Mr Richards had three admissions under S2 of the Mental Health Act into hospital in quick succession: first admission was 12/04/14 to 12/05/14 and the second was from 28/08/14 to 29/09/14. Both admissions resulted from mental and behavioural disorders due to the use of legal highs: Following each admission Mr Richards returned to supported accommodation: On 17*h February 2015 Mr Richards was admitted for the third time under s2 Mr Richards was noted to be vulnerable to exploitation; had exhibited aggressive behaviour when under the influence of legal highs and expressed suicidal thoughts As in the two previous admissions Mr Richards improved such that the 28 detention under S2 was allowed to lapse and Mr Richards was effectively free to leave the psychiatric ward. Mr Richards had nowhere to go as a result of his former accommodation no longer being available Mr Richards had received a number of warnings from the landlords of his supported accommodation and it was felt the accommodation no longer met his needs his placement was not sustainable due to his previous behaviour_ Mr Richards had no choice but to remain on the psychiatric ward whilst an alternative placement was found for him: Mr Richards was extremely distressed at being on the psychiatric ward with no clear idea of when and where he might move. The delay in finding a placement was a source of frustration to medical professionals. On 15th June 2015 Mr Richards transferred the psychiatric ward to Highbridge Court, Old Municipal Buildings, Corporation Street, Taunton, Somerset; TAT 4AQ Tel 01823 359271 Fax 01823 355060 The day and from

Berrow Road, Burnham On Sea, Somerset There was no formal handover. Although a discharge plan was in place it highlighted risks to others rather than to Mr Richards himself. The evidence was that there was insufficient detail in the plan about the support Mr Richards would be offered at Highbridge court. Mr Richards exhibited behaviour showing signs of distress and anxiety, he stepped out in front of cars on two occasions, superficially cut his head with a knife and tried to access bleach in a locked cupboard. The staff at Highbridge court exercised a somewhat haphazard observation policy. Follow up from the Mental Health Team was limited and the Crisis Resolution Home Treatment Team had to be called to Highbridge Court and assessed Mr Richards reporting he did not want to return to hospital and that he should be visited daily for the next five This did not happen and there was only telephone contact with staff rather than face to face meetings with Mr Richards. On 2glh June 2015 Mr Richards was found hanging and he subsequently died on 3r July 2015_

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.