Source · Prevention of Future Deaths

Michael Worrall

Ref: 2014-0179 Date: 22 Apr 2014 Coroner: R Brittain Area: London Inner (North) Responses identified: 0 / 1 View PDF

The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.

Date 22 Apr 2014
56-day deadline 17 Jun 2014 est.
Responses identified 0 of 1
Mental Health related deaths

Coroner's concerns

AI summary
The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.
View full coroner's concerns
During the course of the inquest the evidence revealed matters giving rise to concern. In  my opinion there is a risk that future deaths will occur unless action is taken. (1) The limited availability of psychological therapy at Avesbury House could be significant for patients who, prior to transfer there, were receiving such input. The concern was raised by Mr Worrall’s family, which I share, that this period of discontinuation of psychological  input might have adverse consequences on subsequent discharge into the community.

Report sections

Investigation and inquest
The investigation into the death of Michael Harry WORRALL, aged 28, was opened on 20  October 2013 and concluded at the end of the inquest on 11 April 2014. The conclusion of the inquest was narrative (Copy attached).
Circumstances of the death
Mr Worrall had longstanding mental health issues, which originated during his teenage  years. In 2012 he was admitted to a medium­secure forensic unit, under the care of BEH.  He underwent psychological assessment during this admission. The recommendation of  the psychologist was that, on discharge, Mr Worrall should have ongoing psychological  treatment.  

In 2013 Mr Worrall was transferred to the low­secure unit at Avesbury House, also under  the care of BEH. The intention was that this would be a short admission in order to  facilitate his discharge to community services. Mr Worrall’s admission was extended  following an initial decline in his mental health and owing to concerns regarding his  concordance with medication administration. This resulted in a three month admission to  Avesbury House. During this time Mr Worrall did not have access to psychological  treatment. I heard evidence at the inquest from   Consultant Forensic  Psychiatrist at Avesbury House, that the waiting list for such input in this setting is  approximately three months.  

Mr Worrall was discharged to community services in July 2013. He did access  psychological therapy in this setting. He also had ongoing review by his community  psychiatric nurse. Despite this contact and an apparent stabilisation in his mood, Mr  Worrall unfortunately died after falling from a bridge in October 2013. There was no  evidence that the lack of psychological treatment at Avesbury House contributed to Mr  Worrall’s death.
Copies sent to
I am also under a duty to send the Chief Coroner a copy of your responseAssistant Coroner R Brittain

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Report details

Reference
2014-0179
Date of report
22 April 2014
Coroner
R Brittain
Coroner area
London Inner (North)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Jun 2014 (estimated).

Sent to

Barnet Enfield and Haringey Mental Health NHS Trust

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