Astonn Mitchell-Male · Prevention of Future Deaths report

On the 11th November 2016 I commenced an investigation into the death of Astonn Mitchell-Male. The investigation was concluded by way of jury inquest on the 25th July 2018.

Mr Mitchell-Male was known to suffer from Schizophrenia/Psychosis and had been under the care of Psychiatric services for a number of years. He had a history of attempts at self harm, non-compliance with medication, substance misuse and a tendency to self-medicate. He had also come into contact with the criminal justice system.

At the time of his death he was living within the community in supported accommodation and had a care co-ordinator. Between August and October 2016 the mental health service showed signs of deterioration, resulting in periods of detention under the Mental Health Act (S.136, S.135 and S.2).

On the 31st October 2016 police were contacted at around 21:14 by the on-call Support Worker with a concern for welfare (based on Mr Mitchell-Male’s mental health issues) and a noise complaint (shouting and noise having been heard coming from Mr Mitchell-Male’s first floor flat by another resident). In light of the mental health element and concern for welfare, the call was graded as requiring allocation within 40 minutes and attendance in the hour. The ambulance service was asked to attend. Both the police and ambulance were delayed. When police arrived at around 23:05, there was no sign of noise/disturbance. They were unable to gain entry to Mr Mitchell-Male’s accommodation. They checked the perimeter of the property, knocked on the ground floor windows and ‘buzzed’ the door bells. There was no response. Police left a short time later and the ambulance was cancelled.

On the 1st November 2016 Mr Mitchell-Male’s mother discovered a voicemail that had been left by her son the night before at around 20:52. He was clearly in distress. She contacted police and arranged to meet up with a police officer at Mr Mitchell-Male’s address. Upon entering the flat at around 09:20, Mr Mitchell-Male was found deceased with multiple stab/incise injuries which were the direct cause of his death.

The jury found that Mr Mitchell-Male:

‘...died from multiple self-inflicted stab and incise wounds on or around the evening of 31.10.16 due to a deterioration of his mental state...’ [sic]

& that care provision by the mental health service, police and supported accommodation had been lacking, inadequate and/or insufficient.

1. There is no policy in existence within the Trust to address the process of patient medication monitoring/compliance and the triangulation of corroborative information, particularly within the community setting.

2. There was evidence to show that record keeping was poor and at some points non-existent. Records are a vital form of communication about the patient's condition and care provision. As such, poor compliance goes to the issue of patient safety.