CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report

On 16 July 2013, I commenced an investigation into the death of CHRISTOPHER JONATHAN HIGGINS, AGE 36 YEARS. The investigation concluded at the end of the inquest on 16 DECEMBER 2015. The conclusion of the inquest was Medical Cause of Death: 1a) Severe head injury with extradural haemorrhage (operated on) and Conclusion: Suicide

On 23 December 2013 Mr Higgins became a voluntary patient at the Fermoy Unit. On 24 June 2013 Mr Higgins self-harmed resulting in a wound to his neck. He was taken to the Accident and Emergency Department, Queen Elizabeth Hospital, King's Lynn. Whilst being treated, Mr Higgins grabbed a pair of scissors and repeatedly stabbed himself in the chest. He was restrained. Mr Higgins received medication and was returned to the s136 Suite at the Fermoy Unit. Whilst there he was taken out for a cigarette and dived over the railings landing on the ground below, sustaining a head injury. Mr Higgins was taken to the Queen Elizabeth Hospital, King's Lynn and then transferred to Addenbrooke's Hospital where he died as a result of the head injury on 2 July 2013.

(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation.
(2) The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for instance the Police. In particular, Mr Higgins who had been acting in an unpredictable, and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him. The evidence did not reveal that this had been considered by the Mental Health staff previously attending to Mr Higgins;
(3) The safety of the environment where the incident took place, namely a disabled ramp with a railing along the edge and a concrete floor, had not been risk assessed prior to taking Mr Higgins outside for a cigarette. It is understood that since Mr Higgins' death the railing has been heightened. There was no evidence of a formal Risk Assessment having been undertaken since his death. Other ways of making the area safe are still under consideration.
(4) There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who require assessment and treatment at A & E, as a result of which Mr Higgins, was required to wait over 2 hours in a busy, public area, having already self-harmed and shown signs of paranoia.