Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report

On the 7th February 2018 I commenced an Investigation into the death of Karl Qolf Jamil Englemak Cassimjee, aged 30 years, born on 24th February 1987. The Investigation concluded at the end of the Inquest on the 17th October 2018.

The medical cause of death was:
1a. Hypothermia

The conclusion of the Inquest was a short form conclusion of “accidental death”.

1. The deceased had a history of presumed paranoid schizophrenia with psychosis and episodes that had been treated and managed in his home country in Sweden conservatively.

2. In August 2017, the deceased arrived in the United Kingdom seeking employment.

3. He suffered a health relapse and on the 16th August 2017 was referred to the Chester Community Mental Health Team for treatment and care that was to involve inpatient admission at Leekfield Ward at Clatterbridge Hospital, Wirral, Wirral. On the 21st September 2017, the deceased moved to Manchester.

4. On the 31st January 2018, the deceased was detained by British Transport Police at Piccadilly Railway Station under the provisions of Section 136 of the Mental Health Act 1983 and taken to Manchester Royal Infirmary. He was assessed by a Psychiatrist and diagnosed as requiring further engagement with the Mental Health Home Treatment Team (hereafter MHTT) and police returned him to his residence.

5. Upon being delivered to his home address, the deceased became agitated and distressed. British Transport Police Officers assumed the assessment was worse than this observed. This caused the decision to be taken at the Manchester Royal Infirmary to calm down and settle. No other check or enquiry was made with occupiers of the address. The address in fact, appeared to be empty.

6. A MHTT practitioner attempted contact by telephone which took place on the 1st February 2018 which resulted in no response or reply.

7. The deceased was not at his home address when the MHTT practitioners visited on the 2nd, 3rd, 4th & 5th February 2018.

8. The MHTT reported the deceased as missing on the 3rd February 2018.

9. A Greater Manchester Police investigation established that the deceased was last seen alive on the 2nd February 2018 at the Midland Hotel, Manchester whilst acting in an irrational and bizarre manner.

10. On the 5th February 2018 his body was discovered in a collapsed, unresponsive condition in a semi-remote temporary industrial site where the land had been contaminated by heavy damaged open fields near Unit 2, Bridgewater Avenue, Ordsall, Bolton. Paramedics pronounced him dead at the scene. Whilst no evidence to explain where the deceased had been between the 2nd and 5th February 2018, the evidence suggested that the deceased was psychotic, deluded, and succumbed to hypothermia as a consequence of the prevailing freezing temperatures and collapsed in muddy terrain and died.

1. Brief circumstances of matter of concern

a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital);

b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner;

c. The assessment, as recorded by the Registrar was accepted to be sub-optimal;

d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team.

e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim).

f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account.

2. Whilst the Greater Manchester Mental Health Trust had conducted a comprehensive Incident Review report that correctly identified:

a. The need for the Community Mental Health Team operational procedure to be revised;

b. The need for a revised Multi Disciplinary Team agenda approach to take place and in such cases;

c. A reminder to mental health liaison practitioners to improve record keeping and adherence to existing systems and protocols, including involving all such practitioners in the “decision making” process;

However, the evidence received at Inquest confirmed that:
i. To date, the operational systems identified as in need of revision and review have not been put in place or actioned;