Ahmedreza Fathi · Prevention of Future Deaths report

On 15 May 2015 I commenced an investigation into the death of Ahmedreza Fathi. The Inquest concluded on the 12th April 2016. The Juries conclusion was,

Suicide on May 13th 2015, Gallow Field Road, Market Harborough, Leicestershire. The circumstances that the deceased came by his death were a combination of plastic bag asphyxia and multi drug toxicity, which we believe to be a deliberate act of suicide. From the evidence presented we are of the opinion that the main two contributing factors to Mr Fathi's actions are; the constant physical pain he was experiencing, and the lack of trust (he developed after acute episodes of anxiety and paranoia) for his support network.
With the evidence presented, we have heard that there was a fragmented incohesive approach to the care and support Mr Fathi received which lacked a strategic lead. On the night of 12th May 2015 there were clear changes in Mr Fathi's usual pattern of behaviour that should have been managed more appropriately. It is evident that there was a breakdown in effective communication which led to partial information being provided and inadequate decisions being made.
Questions to Jury. Q1) Do you agree the cause of death to be 1a. Combination of plastic bag asphyxia and multi drug toxicity? A) Yes. Q2) Following his admission to Leicester Royal Infirmary on 26th March 2015, was Mr Fathi appropriately risk assessed with access to all relevant information, after his return to HMP Gartree? A) No. Q3) Did the care plan approach used by the healthcare teams include sufficient detail to ensure all aspects of his safe-keeping were available to and understood by all relevant staff with direct contact with Mr Fathi? A) No. Q4) Did the prison, primary and secondary healthcare services work together and share appropriate information, and review this regularly, to keep Mr Fathi as safe as reasonably be expected within a secure prison environment? A) No. Q5) On the evening of 12 May 2015, were the changed observation levels appropriate at all times? A) No. Q6) If your answer to question 5 is "no", do you think that different, more appropriate, observations may have resulted in an alternative outcome on this night? A) Yes.

Cause of death

1a Combination of plastic bag asphyxia and multi drug toxicity

Mr Fathi was a serving prisoner on a life sentence at HMP Gartree. He was on an ACCT document for many months and under the ongoing care of the physical and mental health teams, as well as receiving physical health care outside the prison.

He had made several attempts to harm himself in the past, including 4 significant episodes during 2015 when he required emergency treatment out of hospital and had threatened to take his own life on many occasions.

On 12th May he made a comment to a fellow in-mate that he intended to take his own life that night, and his observation levels were increased, but not to an appropriate level according to the jury's findings of fact.

He was discovered in his cell during the night, his head and chest inside a large plastic bag in a collapsed state and resuscitation efforts were unsuccessful. Toxicology revealed high levels of drugs, both prescribed and non-prescribed, that he should not have in his possession.

1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison.

2. The enhanced case management system referred to in PSI 64/11 was under-utilised for a prisoner of this complexity and further consideration should be given to its role in situations of this nature.

3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes. This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions. Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt.