Sean Robert Steven Owen · Prevention of Future Deaths report

On the 16 June 2019, I commenced an investigation into the death of Sean Robert Steven Owen (dob: 23 07 1965). The investigation concluded at the end of the inquest on 23 October 2020. The inquest determined that the medical cause of death was 1a) pneumonia 2) hypoxic ischaemic encephalopathy secondary to cardiac arrest secondary to penetrating neck injury. I returned the following Narrative Conclusion:
Against a background of paranoid schizophrenia, the Deceased died by means of a self-inflicted penetrating injury to his neck using a serrated knife at a time when he was experiencing psychotic symptoms. He was under the care of the Community Mental Health Team at the time of his death and it was recognised that he posed a significant risk to himself when non-compliant with medication. The arrangements in place for monitoring his medication compliance and managing the risks posed when he became unwell were inadequate. Whilst the evidence does not show to the required standard that those failures caused or contributed to his death, it is possible that his death would have been averted had more robust care arrangements been in place.

The Deceased had a long-standing history of paranoid schizophrenia which was treatment resistant. From 2014, he had been maintained in the community through depot medication. In October 2018, he refused to accept the depot injection and was switched to oral medication. He became non-compliant with his medication and following an overdose was admitted to Hollingworth Ward at Birch Hill Hospital under section 2 of the Mental Health Act 1983 on 6 December 2018.
The section 2 was rescinded on 31 December 2018 and during January 2019 there were two episodes when the Deceased took overdoses and evidence that he continued to express thoughts of wanting to end his own life. He was discharged from Hollingworth ward on 6 February 2019. He was recognised as a significant risk to himself if he became non-compliant with medication.
The discharge package set up to monitor his compliance with medication had broken down by 21 February 2019 and after that date, his compliance was not monitored. The Deceased was not seen in Outpatient clinic and cancelled the appointments arranged for him on 28 February, 8 April and 2 May 2019. The monthly contact with his care co-ordinator was insufficient in view of the risks of his non-compliance.
On 30 May 2019, the Deceased’s sister alerted the care coordinator to the Deceased’s deteriorating mental state and the Deceased agreed to meet with a psychiatrist. A request for an appointment to take place within 3 to 7 days was faxed to the Community Mental Health Team office.
On 3 June 2019, the Deceased barricaded himself in his own home and severed his jugular vein using a serrated knife. He was taken to Manchester Royal Infirmary and suffered a cardiac arrest en route. He had suffered a hypoxic brain injury and died as a result of his injuries and a chest infection on 14 June 2019.

I heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from in-patient care. The evidence heard at the inquest and recorded in the clinical records was that Mr Owen’s admission to Hollingworth Ward on 6 December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication.
The Discharge Letter that was sent to Mr Owen’s GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician. It omitted references to the overdoses and was erroneous in stating that there had been ‘no issues or incidents’ during the admission; that the Deceased ‘never showed any DSH behaviours as an inpatient’ and that ‘we did not see any SH behaviour or expressed thought from Sean during his admission.’ The letter made no reference to the significant risk associated with non-compliance.