Leah Abby Ratheram · Prevention of Future Deaths report

On 13/10/2016 I commenced an investigation into the death of Leah Abby Ratheram. The investigation concluded at the end of an inquest on 13th March 2017. The conclusion of the inquest was Suicide.

The deceased was known to suffer from autism (Asperger’s syndrome) and foetal alcohol syndrome and resided in supportive living accommodation. She was vulnerable and had previous episodes of self-harm and had been the subject of an assault in February 2016 and had previously been treated by Birmingham and Solihull Mental Health Trust. She presented at A&E at University Hospital Birmingham on 13/09/16 having taken an overdose of 48 paracetamol tablets. She was referred to the RAID team where she was assessed by a nurse at 16.40 and subsequently by a doctor who discharged her with lorazepam and further care from Forward Thinking Birmingham (FTB) home treatment team. FTB took over responsibility for the deceased’s care on 30/09/16. There was no formal handover to this new organisation. On 02/10/16 the deceased put a ligature around her neck which was removed by staff where she was living. On 03/10/16 staff contacted the community mental health team at Warstock Lane but were advised care had been transferred to FTB. 04/10/16 she attempted to hang herself at the home where she was living. Initial attempts to contact FTB were unsuccessful. At 19.30 staff spoke to FTB who advised for the deceased to be taken to A&E at University Hospital Birmingham. She was assessed by RAID and sent home with further follow up from the FTB crisis team. She was on 15 minutes observations at the home who communicated that they were unable to manage this degree of risk. On 05/10/16 numerous attempts were made by the home to contact FTB. She was assessed by the crisis team at 16.00 on 05/10/16 who advised a further assessment by an approved mental health practitioner. This assessment was undertaken at 22.30 which discussed hospital admission. The deceased was reluctant to be admitted to hospital and it was agreed she would be treated at home and reviewed the following day by a doctor with the home manager present. This did not occur. The crisis team attended the home at 17.30 on 06/10 to find the deceased not present from a shopping trip as expected at 17.00. The deceased was reported as missing. At 11.35 on 07/10/16 the deceased was found hanging from a tree branch in woodland close to Stratford Canal, Yardley Wood Road. She was deceased as discovered by paramedics. She had previously purchased 2 locks and a chain from a hardware store at 16.00 on 06/10/16.

Following a post mortem the medical cause of death was determined to be:
HANGING

1. Adults aged between 18 – 25 now have mental health services provided by two organisations – Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust. If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust. If they require ongoing treatment they will be referred to forward Thinking Birmingham. There is a concern that patients will have no coordinated approach to their care at a time of crisis. It is also unclear who will ultimately be responsible for the patient, particularly during the period of transfer.

2. Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process. It was unclear how staff from each organisation would access each other’s records when patients present to one or other of the services.

3. The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed. There is a concern that lack of involvement of this specialty at any early stage will affect the quality of mental health act assessments and the safety of patients.