John Ashley · Prevention of Future Deaths report

On 6th November 2018 I commenced an investigation into the death of John Ashley, aged 57. The investigation concluded at the end of the inquest on 6th December 2019. The conclusion of the inquest was a Narrative Conclusion namely “John Ashley took his own life whilst suffering a deterioration of his mental illness. His deterioration was not fully appreciated by those treating him within the Sussex Partnership Trust and they failed to provide him with the additional level of care that he required. His death was contributed to by neglect. “

Following the Inquest I indicated that I was minded to make a Regulation 28 report but would like to hear submissions from the Interested Persons. An extention for receipt of these submissions was granted to 17th January 2020.

I have fully considered the submissions that I have received in preparing this report.

1. Mr Ashley’s Care and Treatment Plan was not updated when his mental health deteriorated.
2. Staff were not recording interactions with Mr Ashley in the CareNotes system and often emails were not copied into these notes. Therefore there was a lack of compilation of key information relating to Mr Ashley.
3. There was no system in place for Lead Practitioners to be notified of an important entry in a patient’s CareNotes where action was required.
4. Mr Ashley had not been seen by a Psychiatrist for over a year and there was no evidence that the deterioration of his mental health (and his non compliance with his medication) had been reviewed by the professionals weekly team meetings.
5. The Inquest identified that there was a discrepancy in the Trust’s own Policies as to when a Risk Assessment should be reviewed.
6. Save for the duty scheme there appears to be no procedure in place for another practitioner to cover a Lead Practitioner’s case load or any formal handover when they are on leave. Therefore there was no single person who has up todate knowledge of a patient who may be in need or whose mental health was deteriorating.
7. The Inquest heard evidence that the Liasion Mental Health Team at the Hosptial did not make use of patient’s Care and Support Plans or Central Risk Assessment.
8. There was no clear procedure for GPs to be updated by Care Coordinators with details of a patient’s current treatment plan if it had been changed. This was particularly important where there was no regular assessments by a Psychiatrist who would in the normal course of events be providing such updates.