Michael Harry WORRALL · Prevention of Future Deaths report

The investigation into the death of Michael Harry WORRALL, aged 28, was opened on 20 October 2013 and concluded at the end of the inquest on 11 April 2014. The conclusion of the inquest was narrative (Copy attached).

Mr Worrall had longstanding mental health issues, which originated during his teenage years. In 2012 he was admitted to a medium-secure forensic unit, under the care of BEH. He underwent psychological assessment during this admission. The recommendation of the psychologist was that, on discharge, Mr Worrall should have ongoing psychological treatment.

In 2013 Mr Worrall was transferred to the low-secure unit at Avesbury House, also under the care of BEH. The intention was that this would be a short admission in order to facilitate his discharge to community services. Mr Worrall’s admission was extended following an initial decline in his mental health and owing to concerns regarding his concordance with medication administration. This resulted in a three month admission to Avesbury House. During this time Mr Worrall did not have access to psychological treatment. I heard evidence at the inquest from ████████ Consultant Forensic Psychiatrist at Avesbury House, that the waiting list for such input in this setting is approximately three months.

Mr Worrall was discharged to community services in July 2013. He did access psychological therapy in this setting. He also had ongoing review by his community psychiatric nurse. Despite this contact and an apparent stabilisation in his mood, Mr Worrall unfortunately died after falling from a bridge in October 2013. There was no evidence that the lack of psychological treatment at Avesbury House contributed to Mr Worrall’s death.

(1) The limited availability of psychological therapy at Avesbury House could be significant for patients who, prior to transfer there, were receiving such input. The concern was raised by Mr Worrall’s family, which I share, that this period of discontinuation of psychological input might have adverse consequences on subsequent discharge into the community.