Dudley Vincent Brown · Prevention of Future Deaths report

On 17 January 2018, I commenced an investigation into the death of Dudley Vincent Brown (age 58). The investigation concluded at the end of the inquest on 15 May 2018. The conclusion of the inquest was a narrative conclusion which is set out in the circumstances of the death below. The medical cause of death was:
1a: multi organ failure
1b: septic shock secondary to Klebsiella bacteraemia
1c: community acquired pneumonia
2: chronic kidney disease, Wernicke-Korsakoff syndrome.

Mr Brown had a number of health conditions including nephrotic syndrome, epilepsy, Wernicke-Korsakov Syndrome and recurrent pulmonary embolism. He was in receipt of a care package to support him with personal care, meals and medication. Mr Brown’s care package was withdrawn on 27 December 2017 after he threatened his carers with a metal bar. His Social Worker visited on 29 December 2017 and Mr Brown threatened her with a knife. The incident on 29 December 2017 was reported to police, who took no action. Mr Brown’s social worker contacted his GP on 2 January 2018 and the GP referred Mr Brown for an urgent mental health assessment that evening. Mr Brown’s case was passed to the Approved Mental Health Practitioner Service (AMHPS) on the morning of 3 January 2018. A warrant was applied for under Section 135 of the Mental Health Act. This was granted on 8 January 2018. AMHPS also collated information for a Police risk assessment form, which was completed on 8 January 2018. The form was referred to the Police Mental Health Liaison Officer along with the warrant later that day. An appointment was made for the assessment to take place at Mr Brown’s home at 3 pm on 10 January 2018. When Police and the AMHPS attended the property, Mr Brown was found on the floor in a state of reduced consciousness. It is unclear how long he had been there. Paramedics were called and Mr Brown was taken to the Royal London Hospital where he was found to have multi-organ failure. Mr Brown did not respond to treatment and died at the hospital on the evening of 11 January 2018.

(1) Following the incident on 29 December 2017, the incident was reported to police the same day. The social work team leader dealing with the case was of the view that the police were the best placed to initiate emergency procedures under the Mental Health Act.
(2) Mr Brown’s care package was withdrawn on 27 December 2017. No arrangements were put into place for Mr Brown’s welfare to be checked in the period pending a mental health assessment.
(3) The social work team leader dealing with this case was under the impression that referrals to the Approved Mental Health Practitioner Service (AMPHS) had to be made by a GP.
(4) Mr Brown’s referral to the AMHPS and subsequent assessment was delayed due to intervening weekends (including a 3 day bank holiday weekend).
(5) Mr Brown’s assessment by the AMHPS team was delayed due to the need for information regarding the nature of his property being required by the Metropolitan Police as part of their risk assessment.