Aaron James DEELEY · Prevention of Future Deaths report

On 25 February 2022 an investigation was commenced into the death of Aaron James DEELEY, AGE 43. The investigation concluded at the end of the inquest on 24 May 2024. The Jury’s conclusion of the inquest was 1a Multiple Traumatic Injuries with a Narrative:
Aaron James Deeley came to his death by suicide contributed to by neglect on the 14th January 2022 at 01:58. We accept the admissions made by Mid and South Essex NHS Foundation Trust (MSE) as attached.
However, in addition we consider probable, causative factors as follows;

MSE had ample opportunities to make good or replace the windows, as the issues were first reported in April 2019 but had failed to do so by the time of Aarons’ death.

Notwithstanding a Section 5(2) of the Mental Health Act, Deprivation of Liberty Safeguards (DOLS) and Mental Capacity Act paperwork being in place, the security one to one (1:1) was removed, failing to meet Aaron’s requirements for ongoing 1:1 supervision at circa 21:00 on 13/01/2022.

In addition, we consider the following possible causative factors as follows;

Insufficient administration and inadequate record keeping, incidents of these failures include:

- Inconsistencies in completion of the ward Enhanced Observation Form on 13/01/2022,
- Following Aarons’ first suicide attempt the discharge paperwork of the Mental Health Liaison Team (MHLT) assessment on 02/12/2021 was sent to the wrong GP address,
- Discharge paperwork from Southend Hospital on 02/12/2021 was lacking sufficient detail of the intent and the overdose medication,
- Insufficient minutes recorded from the Essex University Partnership NHS Foundation Trust (EPUT) Multi-Disciplinary Team (MDT) on 21/12/2021, to understand the decision to decline the referral of Aaron to the First Response Team,
- On-going COVID restrictions impacting staffing and working environment during November 2021 to January 2022,
- Conflicting understanding of the policy regarding the intervention of the MHLT for patients on the Acute Medical Unit (AMU) ward.

Following several known suicide attempts, over the period November 2021 and January 2022, failings in the care and safeguarding provided by Mid and South Essex NHS Foundation Trust contributed to Aaron James Deeley being able to take his own life. On the 14th January 2022 at around 01:26 Aaron James Deeley took deliberate action to exit from the defective 2nd floor window next to his bed on Acute Medical Unit 1 ward at Southend Hospital. Landing on the ground below, Aaron sustained multiple traumatic injuries resulting in his death at 01:58.

While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.

a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.

There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.