Guy Jeffrey Robinson · Prevention of Future Deaths report

On the 3rd November 2015, I commenced an investigation into the death of Guy Jeffrey Robinson.

Guy was a 31 year old man with enduring mental and physical health problems. He had been diagnosed as suffering from i) emotionally unstable personality disorder, ii) moderate depression, iii) post-traumatic stress disorder and iv) opiate dependence syndrome.

The deceased had a tendency to self-harm and suffered periods of suicidal ideation, usually linked to life events and emotional instability. Furthermore, his physical health problems exacerbated his mental illnesses, increasing his anxiety levels. His ill-health resulted in frequent psychiatric inpatient episodes. Being ‘AWOL’ and absconding were not unusual for Guy, even when ‘under section’.

On the 7th May 2014, Guy was admitted as an informal patient on the mental health unit. On the 21st June 2014 he was compulsorily detained under Section 5 (2); this was subsequently regraded to compulsory detention under S2 MHA on the 23rd June 2014. Guy was ‘under section’ at the time of his death.

His Responsible Clinician had granted S.17 leave, which had been increased over time.

On the evening of the 10th July 2014 Guy left the ward on S.17 leave but failed to return when expected. The ‘AWOL’ protocol was not put in place immediately, rather some 2.5 hours later, as staff took steps to search the hospital and grounds in accordance with what was said to be an agreed local protocol with police.

The Police were called at around 21:13 on the 10th July and following extensive searches in accordance with the Force’s missing person protocols over the next few days, Guy was found deceased outdoors in undergrowth, on the evening of the 15th July 2014.

A post mortem examination and toxicology were conducted.

At inquest, a jury found the cause of death to be:

1a) Multiple drug toxicity

2) Exposure

1. The ‘AWOL’ protocol was not applied appropriately/in a timely manner and during the course of the evidence it became apparent that some of clinicians lacked familiarity with the protocol and process. Whilst the Trust has taken steps to ensure that the protocol has been discussed with all staff based on the ward in question, action has not been taken Trust-wide to ensure that all staff are fully familiar with this policy.

2. Clinical Psychology Service - the only access afforded to a Clinical Psychologist depends upon three pre-requisites being met - i) discharge ii) to a fixed abode iii) onward referral by the Community Mental Health Team. There is no inpatient Clinical Psychology facility and no ability for hospital clinicians to refer a patient directly. This is a significant service gap and potentially prejudices/puts at risk some of the most vulnerable people e.g. those who are of no fixed abode.