Stephen Atherton · Prevention of Future Deaths report

Stephen Atherton died on 16 May 2013, aged 27. On 21 May 2013 an investigation was commenced into his death. The investigation concluded at the end of the inquest on 10 October 2014. The conclusion of the inquest was narrative and the medical cause of death was severe head injuries following a fall from height. This resulted from the consequences of steroid-induced mood alteration. This steroid medication was being used in the management of metastatic neuroendocrine carcinoma (see attached).

Mr Atherton developed shoulder pain towards the end of 2012. At visits to A&E and his GP practice this was attributed to his work as a brick layer. He re-presented to his GP in January 2013. An x-ray of his shoulder demonstrated an abnormality, which the reporting radiologist recommended should be further evaluated by a bone scan. This investigation was requested by his GP and a referral was made to the orthopaedic department at the Royal London Hospital (RLH).

The results of this scan demonstrated findings in his chest, which warranted further investigations that could not be requested by the GP (a CT and MRI). A fax was sent by the GP to the orthopaedic department, requesting that the date of Mr Atherton’s ‘choose and book’ outpatient appointment be brought forward from late March, given the results of the bone scan. This fax was either not received by the orthopaedic department, or received but not scanned into Mr Atherton’s notes. The GP was not able to demonstrate that the fax was successfully delivered.

In early March 2013 Mr Atherton developed problems with his speech. He was referred to the on-call medical team at the RLH and was subsequently diagnosed with a metastatic neuroendocrine carcinoma. He underwent chemotherapy treatment. He was also found to have a metastatic tumour deposit in his brain, which resulted in referral to the neurosurgical department at RLH.

Mr Atherton underwent removal of the metastatic brain tumour in early May 2013. As part of the post-operative management plan he was put onto a reducing dose of steroid medication. His treating neurosurgeon was aware of the potential contribution this was having on Mr Atherton’s low mood but it was felt that he was safe to be discharged on 13 May 2013. Two days later he began displaying unusual behaviour and expressing suicidal ideation to his partner. He was brought to A&E at RLH where he underwent a CT scan of his head. This demonstrated expected post-operative findings only. There were delays in him being seen by the neurosurgical registrar, after which he was admitted to the ward, having been in A&E for almost seven hours. The registrar had discussed Mr Atherton’s case with his neurosurgical consultant and the plan was for an urgent psychiatric assessment, given the history of suicidal ideation.

Following a handover process to a neurosurgical senior house officer (SHO) and from that SHO to the night SHO, the urgency of the psychiatry referral and the history of suicidal ideation was not communicated. As such no referral was made on 15 May 2013.

The following morning Mr Atherton had a further episode of unusual behaviour. He asked to go to the ward television room and was accompanied by a healthcare assistant (HCA). However, he subsequently managed to leave the ward, contrary to the efforts of the HCA. The hospital security staff and police were informed following this incident. However, Mr Atherton was found shortly afterwards, having fallen to his death at a nearby residential housing block.

(1) It was clear from the evidence at the inquest that Mr Atherton’s GP was concerned that he should be seen for orthopaedic review more quickly than had been planned. However, was concerned that, given the importance of this further correspondence, there was no system in place at the GP practice to ensure successful receipt of the fax.

(2) I heard evidence that routine ‘choose and book’ orthopaedic referrals are not clinically triaged by the specialist to whom the referrals are made. As such, the concern was raised (which I share) that there is no potential for the triaging of apparently ‘routine’ appointments which, with specialist input might be expedited. It was clear from the evidence heard that other departments routinely triage referrals and no evidence was provided as to why this is not undertaken by the orthopaedic department.

(3) Mr Atherton required multiple investigations of increasing complexity, at the recommendation of the reporting radiologists. I heard compelling evidence from Mr Atherton’s GP that this process results in delays. This is because the investigations could be undertaken more quickly if the radiologists themselves instigated the necessary additional investigations. This is particularly the case where the suggested investigations cannot actually be requested by GPs. The Trust gave evidence that this process is necessary because of the commissioning arrangements in place, which determine how payment is made for such tests. I am concerned that this process could increase the risk of future deaths occurring in similar circumstances to Mr Atherton’s case.

(4) The neurosurgical ward from which Mr Atherton self-discharged was not locked. This was despite the risk he posed to himself and the fact that the staff were clear he should not be free to leave, without medical assessment of his capacity to self-discharge. I heard evidence that the current legislative framework and case law means that locking of wards is not acceptable. Whilst it is clear that locking ward doors by default is not appropriate, I did not hear compelling evidence as to why mechanisms could not be put in place to facilitate temporary locking. I am concerned that the legal position is being interpreted so that no appropriate safeguards exist, which would have prevented Mr Atherton from absconding. This raises concerns that future deaths could result in such circumstances, if this issue is not addressed.