Mr Tommy Faegh Faisali · Prevention of Future Deaths report

On 30th October 2014 I commenced an investigation into the death of Mr Tommy Faegh Faisali aged 54 years. The investigation concluded at the end of the inquest on Tuesday 9th June 2015. The conclusion of the inquest was:

Medical Cause of Death

1 (a) Acute pulmonary oedema

(b) Methadone toxicity

(c) Liver failure due to cirrhosi

How, when and where the deceased came by his death:

Mr Faisali suffered with hepatitis C which caused cirrhosis. He was also methadone dependent. On 30/9/2014 he was found deceased within his accommodation. There were no suspicious circumstances and no evidence that he intended to take his own life. The cirrhosis impaired his ability to metabolise the methadone.

Conclusion of the Jury as to the death

Drug related misadventure.

It was clear from the evidence taken during the inquest that despite four separate referrals by his GP to psychiatrists over the years, he had never been seen and assessed by one, such that he never received the benefit of specialist psychiatric input into the management of his complex psychiatric and psychological issues. He was only ever seen by CPNs or health care assistants or similar from the psychiatric services, none of whom where qualified to diagnose nor direct treatment.

During the taking of the evidence it became clear that there was no evidence of any documented risk assessment, including suicide risk assessment being performed by the last mental health team providing care to him. His assessment by that team was also not recorded on his psychiatric notes in any contemporaneous way. All that could be found was a letter sent back to the GP after he was seen.

(1) That patients referred by their GP for second opinion from psychiatrists are not being seen by the same but rather by psychiatric health care staff with less qualification to diagnose and assess and recommend treatment then the GP who made the referral.

(2) That a shortage of appropriately qualified doctors is being compensated for by staff without the appropriate qualifications to provide the expert advice being requested by GPs when they make psychiatric referrals.

(3) Those patients may be at increased risk because of (1) and (2) above.

(4) That staff within the mental health teams are not completing risk assessments or at least not appropriately documenting that they are.

(5) That risks to patients, including risk of suicide is thus not appropriately communicated to other team members, thereby increasing the risks to those patients.

(6) That risks arising from (5) are even more increased given the team approach to care and lack of continuity of care inherent in such ways of working.