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Investigation and inquest
On 26ᵗʰ May 2015 I commenced an investigation into the death of Alice MEAD. The investigation concluded at the end of the inquest on 26th May 2015. The conclusion of the inquest was SHE TOOK HER OWN LIFE
Circumstances of the death
See Record of Inquest (attached)
The published report provides this section by reference to another part of the report.
Coroner’s concerns
Alice was known to the Mental Health Services, both as an inpatient and as needing care from community services. She was looked after using the Care Programme Approach.
Three serious failings in her care were identified at her Inquest. It was not possible to say that they were directly contributory to her death at the time (i.e. on the 20ᵗʰ January 2015) but, they have raised sufficient concern with me.
(1) When her Care Co-ordinator left the Trust she was not replaced so Alice was left without one of the corner stones of the Care Programme Approach. Although later a Multi-Disciplinary Team meeting decided she should have a Care Co-ordinator, no action was taken to appoint one.
(2) In spite of Alice calling the Brighton Urgent Response Service twice in December 2014 asking for a medication review and explaining she was not taking her mental health medications, no action was taken to keep her informed of discussions within the Mental Health Service. In particular her request for a medical review was discussed with her Consultant Psychiatrist and he apparently took the view that it was not necessary (poorly documented). Since there was no discussion with Alice, from her point of view, there was a lacuna in her care at a time when she was especially vulnerable, which lasted for several weeks.
(3) Action, if it can be described as action, was only taken when Alice’s young son’s Heath Visitor wrote of her urgent concerns about Alice in good detailed e-mails sent to Alice’s GP and to the Community Mental Health Team on the evening of the 15ᵗʰ January. It was clear that the Mental Health Team should react. Their response was to phone Alice on the 16ᵗʰ and make an appointment to see her on the 28ᵗʰ January.
This “hands off” approach to a known vulnerable patient is unacceptable. The patient should be at the heart of Care Programme Approach care (indeed any care).
(4) There was no evidence that Alice’s risk assessment was reviewed and updated during December 2014 or January 2015. If it was, such reviews should have been documented in accordance with the Care Programme Approach. They were not
