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Investigation and inquest
On Twenty-Seventh May 2020 I commenced an investigation into the death of Sean Daniel FEGAN aged 30. The investigation concluded at the end of the inquest on 25 March 2021. The conclusion of the inquest was that the death was:
Drug related
Circumstances of the death
On or before the 26 April 2020, against a background of autism, complex mental health conditions and drugs misuse, Mr Sean Daniel Fegan took a combination of prescribed and illicit substances, notably ████████ caused his death by means of toxicity. There was no evidence of third party involvement or of suspicion surrounding the death.
Coroner’s concerns
1. Decision making surrounding the need for secondary mental health care – as set out above, a decision was taken in December 2019 that Mr Fegan did not require mental health treatment at all in the absence of adequate information or assessment and for reasons which appeared incorrect.
2. Access to mental health treatment – Mr Fegan had complex mental health conditions and experienced very high levels of distress and anxiety as a consequence. He was declined mental health treatment on two occasions by the Trust. Mr Fegan took an overdose due to his frustration at not being able to access mental health services which he needed. Whilst this was not the cause of Mr Fegan’s death, it created a dangerous state of affairs.
3. Dual diagnosis – it was acknowledged that there was a ‘gap’ within the services in relation to dual diagnosis patients. There was evidence of a resistance to agreeing to provide a service to patients with significant drugs misuse problems.
4. Liaison with family members – there was no evidence of proactive attempts to engage with family members, even when services withdrew. When a family member sought to share concerns, these were rebuffed.
5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan, on an incorrect basis, and without a review of the risk assessment justifying that decision. Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer required.
6. Autism awareness – I was concerned that Mr Fegan’s presentation acted as a barrier to a proper understanding of his mental health needs. In line with his autism diagnosis, he did not present in a socially typical way of expressing his feelings and emotions in a demonstrative manner, but rather ‘jumped’ to his view about what treatment he required, namely prescriptions. This was misunderstood by professionals on more than one occasion.
Information checked against the published report and official responses