Michael John Owen COX · Prevention of Future Deaths report

On 08/09/2017, an inquest was opened into the death of Michael John Owen Cox who died at Ridgewood Care Home, ████████, in Cornwall on 01/04/2017. The inquest concluded, after a four-day hearing before a jury, on 13/06/2019. The jury recorded a conclusion of misadventure due to drug/alcohol use.

Michael had a long history of mental illness. He had previously been diagnosed with paranoid schizophrenia and had been detained under section 3 of the Mental Health Act. This had been suspended and a Community Treatment Order was in place. For a number of years, Michael had lived at a specialist facility in Wales. In 2016, the therapeutic relationship broke down and Michael was recalled to Fletcher Ward at Bodmin hospital. There were concerns about his drinking and he agreed to enter a detoxification programme. His consumption of alcohol, however, did not appear to affect his mental health and at the time of his recall he was not acutely unwell.

As he was not acutely unwell, it was recognised that the hospital ward was not an appropriate venue for him to live. Attempts were made to find a placement for him in the east of the county but these were unsuccessful. Michael’s history of threatening violence to others and being involved in assaults together with previous episodes where he set fire to property and himself is likely to have been a factor in the number of placements that were potentially available.

A placement was found for Michael at Ridgewood care home in Camborne. He moved there in July 2016. The home had a zero tolerance policy to alcohol. In March 2017, it became apparent that Michael had been drinking secretly and it seems likely (although there is no evidence of this) that this had been on-going for some time. There had been no witnessed deterioration in his mental health or mood.

The situation was discussed with the Responsible Clinician and others. As there had been no deterioration in his mental health, there was no basis in law for recalling Michael to the acute ward. The care home, however, did not have staff with qualifications or experience in dealing with clients who had addiction or substance misuse issues.

Michael was found deceased in his room on the morning of 01/04/2017.

The potential shortage of suitable placements for individuals with a mental health history similar to Michael. Evidence was heard at the inquest that when such individuals are placed at a suitable facility, it can become their home and they may live there for years and even decades. Accordingly, spare places can be at a premium. Evidence was also heard that social workers (and in this case an occupational therapist) have persistent difficulties in finding suitable placements suggesting that resources are limited.