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Investigation and inquest
On 20/07/21 an investigation was commenced into the death of Christopher Paul Vickers. The investigation concluded at the end of the inquest on 29/02/24.
The conclusion of the inquest was:
The Deceased, who suffered a worsening of symptoms in respect of his mental health conditions and ADHD, ended his life during an acute on chronic episode.
The medical cause of death was:
1a) Pressure on the neck from a ligature
Circumstances of the death
The Deceased had received assessment and treatment from primary and secondary care in relation to his mental health conditions and ADHD and had been assessed by the local authority in early 2020 and found to have specific needs.
From the end of 2020 there was a worsening of the deceased’s symptoms and behaviours. The deceased reported that the impact of the COVID-19 pandemic had affected his mental health and ADHD and was a factor in exacerbating his symptoms of anxiety and intrusive thoughts.
From June 2021 there was a further escalation of the Deceased’s behaviours and risks of self-harm and harm to others, resulting in an increase in referrals and contacts to agencies by the Deceased’s family and other professionals for support, assessment, and treatment.
The Deceased underwent triage and full assessments by the crisis team and a review by the ADHD team, which ultimately resulted in a referral to and assessment by the community treatment team, who agreed to provide treatment on 25/06/21 and the Deceased was placed on their waiting list. The Deceased was prescribed medication to address anxiety and lack of sleep.
Despite the known escalation of behaviours, the increase in the risks to self and to others, and the fact that the Deceased was open to various agencies and services, there were multiple repeated missed opportunities by different organisations to instigate a safeguarding referral for formal safeguarding supervision, or to convene a multi-disciplinary or multi-agency meeting to co-ordinate the Deceased’s care with the provision of a shared care plan.
The Deceased was found on 18/07/21 with a ligature around his neck and death was certified on 18/07/21 at 18.06.
Coroner’s concerns
1. There were multiple repeated missed opportunities to co-ordinate the Deceased’s care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.
2. There were multiple repeated missed opportunities to make safeguarding referrals for formal safeguarding supervision from the safeguarding adult public protection team despite known escalating risk to self and to others.
There remains a risk that future deaths could occur as the missed opportunities were significant and multiple and relate to clear processes and policies that were not followed. Current action that has been undertaken does not address my concerns.
Information checked against the published report and official responses