Mr Matthew Jones · Prevention of Future Deaths report

On 5 April 2018 the Acting Senior Coroner for Bedfordshire & Luton commenced an investigation was into the death of Mr Matthew Jones, aged 35. The investigation concluded at the end of the Inquest held by me, on 16 May 2019, when my determinations and conclusion were delivered. The medical cause of death was found to be:

1a Cocaine Toxicity

The Conclusion of the Inquest was a Narrative Conclusion:

The Deceased’s death was drug-related but his discharge from hospital to accommodation which was not supported more than minimally, negligibly or trivially contributed to it.

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The Deceased had a diagnosis of paranoid schizophrenia and polysubstance misuse and was under the care of Probation, Community Mental Health and Drug & Alcohol Support Services. A relapse in his conditions led to him being evicted from his accommodation on 8 February 2018 and it was agreed at a Professionals Meeting on 9 February 2018 that he required supported accommodation. After subsequently suffering threats at his temporary emergency accommodation, he was admitted to Ash Ward, Oakley Court, Bedfordshire, on 20 February 2018 for further treatment. Although he remained on Ash Ward until 29 March 2018, neither the Mental Health nor the Housing Teams proactively sought supported accommodation for him and he was discharged from Ash Ward back to temporary accommodation in Luton on the afternoon of 29 March 2018. Shortly after midnight that evening, he was found behaving erratically on a street corner connecting Farley Hill with Whitehall Avenue in Luton and soon after suffered a cardiac arrest. He was taken by attending paramedics to the Luton & Dunstable Hospital but his death was confirmed there at 03.40 hours. Post-mortem examination confirmed a Cocaine blood concentration of 3.0 mg/l.

The evidence at the Inquest, the evidence revealed:

(i) an absence of appropriate training for clinicians and healthcare workers involved in the delivery of mental health services who have responsibility for the care of persons subject to Community Mental Health Treatment Orders (linked to Mental Health Treatment Requirement Care-Plans including treatment by Drug & Alcohol Services); and, as a result,

(ii) a poor appreciation, including a lack of co-ordinated and multi-agency working, by such clinicians and healthcare workers of the likely risks of non-compliance with treatment linked to Community Mental Health Treatment Orders, and, particularly, of the importance of ensuring that ‘housing’ is part of any hospital discharge planning.