Kim Morris · Prevention of Future Deaths report

On 24 September 2018 I commenced an investigation into the death of Kim Morris

The Inquest concluded on 26th July 2019

Cause of death:
1a Hypoxic brain injury
1b Hanging – suspension by ligature

Kim died from the consequences of suspension by ligature; losing her life in the Leicester Royal Infirmary on 22nd September 2018 having been found in the garage at home and resuscitated on 20th September 2018.

Coroners Conclusion:
Kim had been receiving treatment for her mental ill health for many years in primary care and only occasionally in secondary care until she went into crisis during 2018. Admission to the local crisis house was prematurely terminate due to the in-appropriate admission of another patient whose interactions with Kim made her feel unsafe and she therefore lost a positive therapeutic opportunity not only on that occasion but on future occasions as well.

She felt unable to engage fully with the crisis team due to a significant lack of continuity of care and this impacted on her negatively. She took her own life the day after that treatment concluded, but her intention at that time was unclear.

Mrs Morris was referred to the crisis team on more than one occasion but particularly as part of her discharge plan from ward based care in the Bradgate Unit, a mental health hospital during August 2018 having taken a significant overdose. It was clear from the notes that there were numerous visits and telephone encounters, with numerous different individuals, and the role of the key worker did not appear to reduce or impact on the number of different team members having separate contacts with Mrs Morris. It was accepted that she should be referred to a Community psychiatric nurse to continue her engagement and this may bring some continuity of only having to speak to and engage with one person. It was not apparent that actual contact had been made prior to her discharge from the crisis team.

The court was told that due to the team set up, that continuity of visits was not possible and that the demands on the teams service significantly outweigh the resources available. The service remains on the Trust’s “at risk” register.

There is no indication in the extensive notes that any efforts were made to alleviate the distress that Mrs Morris felt by having to repeat her story on each occasion to each new team member, or to try and find a better way to engage with her or improve continuity. The handover to the CPN was not carried out in a way that was apparent to Mrs Morris and potentially left her fearful of another delay in receiving help and treatment. She took her life the day after discharge from the crisis team.

My concerns are that the team is not offering a service that is suitable to support such high risk individuals and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care. This is not a new, but a continuing situation that I have considered before and it remains unresolved.