Sandra Brotherton

On the 3Oth November 2016 I concluded the Inquest into the death of Sandra Brotherton date of birth 10.07.1954 who died on the 31.12.14 at her home address in Bredbury Stockport. The cause of death was 1a) Multiple Stab Wounds [recorded that the deceased died on the 31s December 2014 at her home address. She was killed by an individual who had dual diagnosis of paranoid schizophrenia and Aspergers For several the deceased had been in hospital and the individual who had no insight into his illness at been at the home address alone: It is probable that he had not been eating, sleeping or taking his medication this period of time and had experienced breakthrough in his symptoms: When the deceased arrived home he was exhibiting agitated and disturbed behaviour and killed the deceased a few hours after she arrived home Conclusion Unlawful Killing CIRCUMSTANCES OF THE DEATH The Inquest into the death of Sandra_Brotherton was resumed following criminal trial in which the offender; had been sentenced to hospital order. There were matters of concern raised surrounding his involvement with Mental Health Services. had a dual diagnosis of Paranoid Schizophrenia and Aspergers Syndrome He had been sectioned many years ago for a short period of time but had subsequently been cared for at the address by Sandra Brotherton who was predominantly his sole carer: required_prompting to do many daily_tasks including_washing_dressing, Acting days during home eating and taking his medication: was described by several witnesses as someone who had residual symptoms of his psychosis and lacked understanding and insight into his condition. He never accepted that he was unwell Sandra was the of aggressive behaviours and we heard evidence f the arguments which might occur between them and off name of over many years when he called her such as "witch and satan" . Sandra aS the main carer and indeed main person in life who bore the brunt of his behaviour and verbal aggression: Package of Care_in place for) The Court heard how was under the care of mental health services_ He was treated with medication which was reviewed and until 2014 he was under the care of the Community Mental Health Team; EIT. This was then transferred to Recovery and Intervention Team (RIT) Under both services had & care co-ordinator: Indeed the difference on practical level for was the change in his worker: In addition_ had a Personal Assistant which was for through the Direct payments scheme of the local authority who had been in place since 2006. Contingency Given that Sandra was effectively the sole carer forl questions were asked at the Inquest as to a contingency plan in place should Sandra not be in a position to care for At times the evidence on this was interlinked with the plan for respite care but overall the contingency plans for were simply having provided contact details for the Access and Crisis teams and the Home Treatment team and believing that family were close and on hand to provide support. Information Provided to PA and interaction with Mental Health Services confired it was not until after death that he was aware of Jdiagnosis of Schizophrenia His understanding was that Mental_health services were involved because of diagnosis of autism: was clear_that he received his instructions from Sandra. He had little contact withi care cO-ordinator although there were occasions when he would see her. It was clear from the evidence that was included in the care plan for] but as he stated in his evidence, he would not know ifhe was_ The mental health team were not aware when would be on leave the RIT Team confirmed that she would have expected that the RIT team were aware of when the PA was on leave and haveexpected increased visits by the care cO-ordinator during this time also accepted she could have increased her visits had she known the PA would be away. focus calling things paid Plans very would

August 2014 and Incident on the 1801 September The Court heard evidence of involvement withl and Sandra throughout the August and September of 2014. In August 2014 had received call indicating] was unwell and she carried out an urgent home visit: She indicated that she could see he was unwell, he was agitated_she stated though that he was not delusional: At this stage she advised how_ was 0n leave and she to another Dr who agreed to increase Olanzapine medication: The Court also heard that during this time she tried to get an urgent appointment with Consultant Psychiatrist but this was not possible: A month later the Court then heard evidence about the incident which occured on the 18th September: Sandra told her daughter thatL had lashed out and hit her in the face. There was also some evidence she also told her husband who was abroad but may not have told him the full details We know that she told her sister that had hit her; saying that Jhad tripped and had not meant to do it, she was convinced it was a one off: Also told her sister who felt that] had crossed line and Sandra to seek In addition she did tell that had lashed out at her but when asked, she said that she had reported it to care team: Sandra did telephone Mental health services on the 18h September at no stage in any of the conversations did she say that had assaulted her: We know that she did ring saying that he needed to be re-housed immediately: in her evidence described "trying to make sense of the reasons Sandra wanted lout of the property" and recalled her being "vague" She recalled 'it was almost as if Sandra just wanted him out of the house not that she felt at risk" Sandra was asked about risk and told who documented the same that she did not feel at risk December 2014 Sandra was unwell over the Xmas period and had attended hospital on the 22-23r December. She then reattended and was admitted on the 284h December: At no stage were Mental Health services aware of her admission: When she returned home on the 31s December 2014 she was killed a short time later; CORONERS CONCERNS The concerns noted by the Court the course of the Inquest are as follows:
1) Knowing that Sandra was in effect & sole carer there should have been spoke urged help: during clearly discussed contingency plan foi in the event that there was an emergency and Sandra was not able to provide care.
2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person; where there is no suggestion of a lack of capacity, this should be recorded.
3) It was concerning that the Care Co-Ordinator who visited] in August 2014 was not able to obtain a urgent appointment with Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with dual diagnosis was required. Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014 Having heard the evidence aS to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of a assault but suggestive of potential issue involving a Mental Health service user and it is for this reason that I do find that_there should have been an attempt to see or speak to to see how he was, after there had been suggestion that he needed to his him immediately ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report; namely by 2"d February 2017 1, the coroner; may extend the period. response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION Ihave sent & copy ofmy report to the Chief Coroner and to the following Interested Persons namely, the family and Iegal representatives of the family of Sandra Brotherton: Iam also under a duty to send the Chief Coroner a copy of your response. leave duty days Your explain

The Chief Coroner may publish either Or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: 08.12.2016 Joanne Kearsley Acting Senior Coroner (Vas 5

The Inquest into the death of Sandra_Brotherton was resumed following criminal trial in which the offender; had been sentenced to hospital order. There were matters of concern raised surrounding his involvement with Mental Health Services. had a dual diagnosis of Paranoid Schizophrenia and Aspergers Syndrome He had been sectioned many years ago for a short period of time but had subsequently been cared for at the address by Sandra Brotherton who was predominantly his sole carer: required_prompting to do many daily_tasks including_washing_dressing, Acting days during home eating and taking his medication: was described by several witnesses as someone who had residual symptoms of his psychosis and lacked understanding and insight into his condition. He never accepted that he was unwell Sandra was the of aggressive behaviours and we heard evidence f the arguments which might occur between them and off name of over many years when he called her such as "witch and satan" . Sandra aS the main carer and indeed main person in life who bore the brunt of his behaviour and verbal aggression: Package of Care_in place for) The Court heard how was under the care of mental health services_ He was treated with medication which was reviewed and until 2014 he was under the care of the Community Mental Health Team; EIT. This was then transferred to Recovery and Intervention Team (RIT) Under both services had & care co-ordinator: Indeed the difference on practical level for was the change in his worker: In addition_ had a Personal Assistant which was for through the Direct payments scheme of the local authority who had been in place since 2006. Contingency Given that Sandra was effectively the sole carer forl questions were asked at the Inquest as to a contingency plan in place should Sandra not be in a position to care for At times the evidence on this was interlinked with the plan for respite care but overall the contingency plans for were simply having provided contact details for the Access and Crisis teams and the Home Treatment team and believing that family were close and on hand to provide support. Information Provided to PA and interaction with Mental Health Services confired it was not until after death that he was aware of Jdiagnosis of Schizophrenia His understanding was that Mental_health services were involved because of diagnosis of autism: was clear_that he received his instructions from Sandra. He had little contact withi care cO-ordinator although there were occasions when he would see her. It was clear from the evidence that was included in the care plan for] but as he stated in his evidence, he would not know ifhe was_ The mental health team were not aware when would be on leave the RIT Team confirmed that she would have expected that the RIT team were aware of when the PA was on leave and haveexpected increased visits by the care cO-ordinator during this time also accepted she could have increased her visits had she known the PA would be away. focus calling things paid Plans very would

August 2014 and Incident on the 1801 September The Court heard evidence of involvement withl and Sandra throughout the August and September of 2014. In August 2014 had received call indicating] was unwell and she carried out an urgent home visit: She indicated that she could see he was unwell, he was agitated_she stated though that he was not delusional: At this stage she advised how_ was 0n leave and she to another Dr who agreed to increase Olanzapine medication: The Court also heard that during this time she tried to get an urgent appointment with Consultant Psychiatrist but this was not possible: A month later the Court then heard evidence about the incident which occured on the 18th September: Sandra told her daughter thatL had lashed out and hit her in the face. There was also some evidence she also told her husband who was abroad but may not have told him the full details We know that she told her sister that had hit her; saying that Jhad tripped and had not meant to do it, she was convinced it was a one off: Also told her sister who felt that] had crossed line and Sandra to seek In addition she did tell that had lashed out at her but when asked, she said that she had reported it to care team: Sandra did telephone Mental health services on the 18h September at no stage in any of the conversations did she say that had assaulted her: We know that she did ring saying that he needed to be re-housed immediately: in her evidence described "trying to make sense of the reasons Sandra wanted lout of the property" and recalled her being "vague" She recalled 'it was almost as if Sandra just wanted him out of the house not that she felt at risk" Sandra was asked about risk and told who documented the same that she did not feel at risk December 2014 Sandra was unwell over the Xmas period and had attended hospital on the 22-23r December. She then reattended and was admitted on the 284h December: At no stage were Mental Health services aware of her admission: When she returned home on the 31s December 2014 she was killed a short time later;

1) Knowing that Sandra was in effect & sole carer there should have been spoke urged help: during clearly discussed contingency plan foi in the event that there was an emergency and Sandra was not able to provide care.
2) Where a Personal Assistant is integral to the Mental Health Service Care plan there should have been a clear and documented record that the care plan should be provided to them. If there is an objection to confidential medical information being shared by the relevant person; where there is no suggestion of a lack of capacity, this should be recorded.
3) It was concerning that the Care Co-Ordinator who visited] in August 2014 was not able to obtain a urgent appointment with Consultant Psychiatrist (in what is a multi-disciplinary team) at a time when she felt an urgent appointment for someone with dual diagnosis was required. Whilst his medication was increased at this stage he was then not seen by a Consultant until October 2014 Having heard the evidence aS to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of a assault but suggestive of potential issue involving a Mental Health service user and it is for this reason that I do find that_there should have been an attempt to see or speak to to see how he was, after there had been suggestion that he needed to his him immediately ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report; namely by 2"d February 2017 1, the coroner; may extend the period. response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must why no action is proposed. COPIES and PUBLICATION Ihave sent & copy ofmy report to the Chief Coroner and to the following Interested Persons namely, the family and Iegal representatives of the family of Sandra Brotherton: Iam also under a duty to send the Chief Coroner a copy of your response. leave duty days Your explain

The Chief Coroner may publish either Or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: 08.12.2016 Joanne Kearsley Acting Senior Coroner (Vas 5