Carl Garry Thompson · Prevention of Future Deaths report

On 11th March 2022 an investigation was commenced into the death of Carl Garry Thompson. The investigation concluded on the 17th February 2023 and the conclusion was one of Drug-Related Death. The medical cause of death was 1) Drug Toxicity; 2) Hypertensive Heart Disease

At the time of his death on the 9th March 2022, Carl was on s.17 Mental Health Act (MHA) leave from the Arden Ward, Stepping Hill Hospital where he was an inpatient under s.3 MHA. Carl had been granted leave by his Responsible Clinician on the 4th March and his leave commenced on the 7th March. He was granted 5 days overnight leave and should have returned to the ward on the 11th March.

The jury made the following findings in relation to the circumstances of Carl’s death:

Carl Thompson was found unresponsive in the bedroom of his house at 01:00 by his daughter on 10th March 2022. Ambulance staff attended at 01:39 and declared him deceased as a result of a drug overdose. Mr Thompson had last been observed to be alive before 9:30pm on the evening of 9th March 2022, when he was thought to be in a deep sleep, observed by his daughter. Due to the post mortem condition of the deceased upon being found, it is likely that he died on the night of the 9th March 2022. Mr Thompson's death was probably contributed to by a failure of producing and regularly updating adequate risk assessments in relation to the planning of his section 17 leave and updating them following reported family concerns. In addition, it is possible that Carl's death was contributed to by a failure of both the hospital ward staff and the Community Mental Health Team. The response and lack of escalation following family concerns by ward staff was inadequate. Further to this, it was a failure by the Community Mental Health Team practitioner who assessed Carl via telephone on 9th March 2022, when in fact this should have been carried out face to face.

1. I am concerned that the jury have found that the risk assessments and risk planning for Carl’s s.17 leave in March 2023 was inadequate. This issue was not addressed in the Trusts’ internal investigation conducted by ████████ and I have not received any evidence that there have been reflections or changes following Carl’s death on this issue to reassure me that there is not a continuing risk of future deaths.

2. I am concerned that the Trust’s own internal review found that whilst Carl was on leave from the 7th March, the clinical team were made aware of an increase in Carl’s risk factors when contacted by his mother who outlined her concerns.

3. The review concluded that this represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for Carl, including his use of non-prescription medication and illicit substance misuse.

4. The Trust’s own review concluded that the clinical team could have sought to understand these risk factors through direct contact with Carl.

5. The Trusts own review concluded that following such direct contact, consultation could have been sought with others within a legal framework to ask Carl to return to the ward with support from services or family. The review concluded that the nursing team could have escalated this information via the on-call system for further medical support.

6. The review concluded that a risk to Carl’s physical health was present especially in view of research and evidence for substance misusers starting to use again after periods of abstaining.

7. I am concerned that on the 9th March, Carl should have been seen face to face by the CMHT, in line with Trust Policy. Instead he only received a telephone call from a duty worker who had never met him.

8. I am concerned that prior to his commencing leave on the 7th March, Carl had not been allocated a CMHT Care Coordinator, despite being an inpatient for over 3 months, since 31st December 2021.

9. ████████ gave evidence that although the Trust Review had identified a number of missed opportunities, the Trust Action plan, which contained 6 Action points was still “In progress”. ████████ was not able to identify a single action point that had been completed to date.