Anthony John William Watson · Prevention of Future Deaths report

On 25/10/2018 I commenced an investigation into the death of Anthony John William Watson. The investigation concluded at the end of an inquest on 29/01/19. The conclusion of the inquest was Suicide.

The Deceased was diagnosed with recurrent depression and anxiety in early 2017 and was being treated by mental health services. In mid-May his mental health declined quickly and by 18/10/18 he was displaying signs of psychosis, and reporting that he was thinking of taking his own life by jumping from a height. Mental health services felt that an immediate admission was necessary, but no bed was available within the area, and he was placed on a waiting list. To mitigate the risk of the Deceased harming himself whilst awaiting a bed, he was referred to community mental health services who visited him at home on 18, 19 and 20. A visit was planned for the afternoon on 21/10/18. On the morning of 21/10/18 the Deceased was at home and in his first floor bedroom, he cut both wrists and his neck, and jumped through an open window, landing on the patio causing a significant head injury. He had left a note indicating an intention to end his own life. He was taken by Paramedics to Queen Elizabeth Hospital, Birmingham. A CT-scan revealed the fall from height caused an unsurvivable right-sided subdural haemorrhage. He died at 14:26hrs on 22/10/18.

Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:
1a. CATASTROPHIC HEAD INJURY
1b. FALL FROM HEIGHT
2. POLYTRAUMA

1. Mr Watson was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area. Three days later there was still no bed available. Mr Watson was not offered a bed out-of-area.
2. This report has similar themes to the 7 reports issued by the Birmingham and Solihull Coroners on 4/10/18.
3. However, the impact of Mr Watson’s age is a new issue.
4. I heard evidence that:
a. Younger and older adults will not normally be admitted as inpatients on mixed units. Beds on young adult units may have been available on 18-22 October 2018 but these were not considered.
b. Beds in neighbouring areas are unavailable because of contractual issues. The closest out of area option is at least 70 miles away. Although Mr Watson was not offered an out of area bed, his wife was confident that had one been offered he would have declined because 70 miles was so far away. Whilst this distance is likely to deter a patient of any age from accepting the offer, it is particularly problematic for elderly patients and their families.
c. Whilst remedial action is underway in response to the concerns raised in the 7 reports issued on 4/10/18, currently it still remains the position that at least one patient every day in Birmingham and Solihull is advised they require an immediate admission for inpatient mental health treatment but no bed is available within the area.
5. The lack of inpatient beds is a resource issue. My ongoing concerns are that (a) there are insufficient numbers of beds in Birmingham and Solihull, and (b) out-of-area beds are too far away.