Reece Tristan Lapina-Amarelle · Prevention of Future Deaths report

On 29th June 2018 I commenced an investigation into the death of Reece Tristan Lapina-Amarelle, aged 20 years. The investigation concluded at the end of the inquest on 25th April 2019. I am attaching a copy of the Record of Inquest. The conclusion of the inquest was suicide and the medical cause of death was multiple injuries.

Two documents were presented to me which are a powerful statement of the peculiar problems the authorities faced in Mr Lapina-Amarelle’s situation. I can do no better than to attach copies of those documents. They are the statement of Doctor ████████, the psychiatrist responsible for him when he was admitted (on very many occasions), coupled with the Level 2 Comprehensive Serious Incident Review Report. A study of those two documents will give the history and it can be seen that all available in-patient and community programmes had been unsuccessful, and the Sussex Partnership Foundation Trust (the Mental Health Services) simply had no other option but to detain him in hospital or to discharge him. He had been providing drugs to other in-patients in hospital and so understandably they did not want him to continue there. They therefore discharged him with the full knowledge that he would immediately proceed to try to take his life, which is exactly what he did. The only preventative measure that the Trust could take was to telephone the Beachy Head Chaplains and the Police to warn them that Reece was on his way to Beachy Head.

(1) There are no resources and no system of treatment for people who present with serious mental illness and alcohol or drug misuse histories.

(2) There is insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse Service).

(3) That latter service is voluntary and, outside the criminal justice system, the subject cannot be forced to access and receive help or to cooperate with that service.

(4) In my opinion the Mental Health Act is out of date in that it does not recognise or accept responsibility for providing a plan of action to deal with people such as Reece.

(5) Twenty years ago the connection between the use of strong drugs in teenage years and subsequent mental health (often very serious) was not fully recognised. However nowadays there is far greater use of drugs which are growing ever stronger, and a very considerable number of people with mental health issues in prison or in the community have developed or worsened their conditions by the use of cannabis and other illegal substances. The Mental Health Act still concentrates on therapy without giving sufficient emphasis, in my view, to safety and, in blunt terms, keeping people alive.

In my view without action these issues are simply going to get worse.