David Reginald Bert Stacey · Prevention of Future Deaths report

On 08 December 2017 I commenced an investigation into the death of David Reginald Bert Stacey

The inquest concluded on 14 December 2018 before a jury.

Cause of Death 1a) Chest injuries sustained in a road traffic collision.

The findings of the jury in Box 3 were ‘Mr Stacey was in his Toyota car on the A4304 Theddingworth Road at 11.02 on the 27th of November 2017, after a road traffic collision. Despite medical treatment he was pronounced dead at the scene. The road traffic collision was attributed to Mr Stacey driving at approximately 78 MPH and crossing the double solid central line into oncoming traffic.’

The jury’s conclusion in Box 4 was:-

‘On the 27th of November 2017at 00:23 the police received a 999 call from Mr Stacey's neighbour that Mr Stacey was at his neighbours home and had allegedly been attacked. The police attended and took Mr Stacey back to his own home. Mr Stacey was agitated and worried the I.R.A were after him. The police decided that Mr Stacey needed to be seen by Triage Car to be assessed and they were called. Triage Car arrived and the senior mental health nurse spoke to Mr Stacey and decided he needed to be assessed under section 2 of the mental health act. The mental health act assessment team were contacted and the Triage Car nurse gave a handover to one of the doctors. The doctors agreed he needed to be assessed and said they would attend after they had finished their current assessment. The Triage Car team informed the police the mental health act assessment team were on their way and they could leave when the next mental health act assessment team arrived. The mental health act assessment team arrived and were given a handover by the police. We feel unanimously that the handover was appropriate. After the handover the police left and we feel unanimously that the police officers should not have remained at the property whilst the assessment was taking place. We feel unanimously that there was no further police presence needed despite the calls made. During the assessment there was concern by the mental health act assessment team, however we feel unanimously that Mr Stacey's behaviour did not warrant the mental health assessment team leaving the premises. The doctors made the recommendation that Mr Stacey should be detained under section 2 of the mental health act and the AMHP accepted their recommendations. We feel unanimously that the AMHP became responsible for Mr Stacey's safety.
After the assessment, the mental health act assessment team decided to leave the building and Mr Stacey was left alone. We feel unanimously that the level of risk was assessed appropriately as a high level of risk. The mental health act assessment team then convened in a car outside to finish paperwork and escalated the case on to their respective line managers. Mr Stacey had no further known contact until 10-12 AM on the 27th November when a 999 call was made by him. In this call he repeatedly used the phrase "violent line", so we unanimously feel, that Mr Stacey was still suffering psychotic symptoms. Mr Stacey was then involved in a fatal road traffic collision at 11.02AM on 27th November 2017. We accept the admission by the Leicestershire Partnership Trust that a bed was available for Mr Stacey and find that it was not communicated properly due to a serious failure in their process.
Additionally we find that Mr Stacey's death was "contributed to by neglect by the mental health act assessment team" due to the team leaving Mr Stacey's property before other safeguards had been put in place.

An expert was instructed to advise on the psychiatric aspect of Mr Stacey’s death. One of the issues he identified was a failure to identify availability of a bed for cases of special urgency. This is a statutory requirement under section 140 of the Mental Health Act 1983 that the relevant health bodies (local Clinical Commissioning Group and Local Health Board) give advice to every social services authorities within the area of arrangements that are in force for the reception of mentally disordered patients in cases of special urgency. The expert was in no doubt that Mr Stacey would have fulfilled the ‘special urgency’ category. It transpires from my further communication with the Leicestershire Partnership Trust that there is no such facility in Leicestershire. It would appear to be a statutory requirement that is currently being ignored and I am concerned that another similar situation might arise when there are no beds available to or identifiable by, the local Trust.