Michael Paul Wheeler · Prevention of Future Deaths report

On 2nd August 2018 I commenced an investigation into the death of Michael Paul Wheeler and an inquest is listed to take place on the 7th December 2018.

Mr. Wheeler died as a result of jumping from a fourth floor window at the home of his brother with whom he was staying on the 26th July 2018. Mr. Wheeler had attended the Queen Elizabeth Hospital Birmingham on the 24th July 2018 because he was demonstrating extreme paranoia. He was concerned for his own safety and that of family members to the extent that he was trying to stop family members from leaving the house and had called the police to report that people were coming to attack him when there was no basis for his belief. Mr. Wheeler was seen by a psychiatric nurse from the Birmingham and Solihull RAID team whilst in hospital to who family reported an increase in bizarre behaviour in the last 8 to 9 weeks, including Mr. Wheeler isolating himself and becoming increasingly paranoid. Mr. Wheeler told RAID he would keep himself safe but it was identified by the nurse that he had limited understanding of his circumstances due to his paranoia. The RAID clinician concluded he could be discharged that day but needed to be seen urgently and referred him to the Home Treatment Team (“HTT”) for a review the following day. Mr. Wheeler was visited the following day, the 25th July 2018, by a community psychiatric nurse from the HTT and it was identified that he required a medical review. This was booked for 10am on the 27th July 2018.

Following a post mortem the medical cause of death was determined to be:
1a) Multiple Injuries

1. Mr. Wheeler’s family have provided evidence that he was extremely paranoid by the 24th of July 2018 and this was causing him to act irrationally and at times aggressively, they were very fearful for his safety and reported this to the mental health nurses he saw on the 24th and 25th. Despite these concerns Mr. Wheeler was not reviewed by a Psychiatrist and therefore his condition went undiagnosed with no treatment plan. Furthermore it is noted that there was no plan to review Mr. Wheeler at all on the 26th July 2018.
2. The Coroner is aware, although not from evidence obtained in respect of Mr. Wheeler’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT who are currently operating at 109% capacity and are often not available. Consequently, patients who would otherwise have been offered in-patient treatment, are having to be managed by the HTTs. Partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day. One particular problem in the Birmingham and Solihull area is that the occurrence of psychosis is more than 3 times higher than the national average. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
3. The fact that at the current time HTT cannot always provide urgent medical review by a psychiatrist creates a risk to life.
4. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction may arise from underfunding of mental health services.
5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding.
6. In addition to this report letters are enclosed from the Medical Directors of both Trusts setting out their concerns.