Michael Richard Drewry · Prevention of Future Deaths report

On 3 May 2017 an Inquest was opened into the death of Michael Richard Drewry. That was concluded at the end of the inquest on 18 December 2017. The conclusion after the inquest was:

Medical cause of death:

Hanging

How, when and where the deceased came by his death:

Shortly after 09.00 on 3 April 2017 Mr. Drewry was discovered by his wife at the foot of the stairs at the family home in Beeston, Nottingham. Wrapped around his neck and the newel post at the foot of the stairs was blue fabric taken from some pyjamas that had been fashioned into a ligature.
Despite CPR, resuscitation and emergency hospitalisation, Mr. Drewry suffered an unsurvivable hypoxic brain injury. In consultation with his family Mr. Drewry’s life sustaining therapy was withdrawn at 20.36 on 8 April 2017 and he died shortly after at 20.47 at the Queens Medical Centre Nottingham.

Conclusion of the jury as to death:

Mr. Drewry died as a result of injuries sustained from a self-administered ligature.

The deceased had a background of periodic bouts of anxiety and low mood beginning in about 2007. His condition fluctuated and was, from time to time, well controlled with, amongst other drugs, fluoxetine.
In January 2014 he required hospitalisation after an acute bout of anxiety in the workplace.
Towards the conclusion of 2016 the deceased’s mental health began to deteriorate and, by February 2017, he required emergency hospitalisation. Matters were exacerbated by the death of his sister during his period as an inpatient.
The deceased was discharged into the community.
On or about 9 February the deceased held a knife and expressed a desire to ‘cut out the bad piece’.
By late March the deceased’s mental health began to deteriorate. On 30 March he had a panic attack, held a knife to his chest and said ‘I would never do this but I can’t live like this’. Overnight in to 31 March he suffered a panic attack during which he injured his hand. His wife took him to A & E where he was prescribed diazepam. He was seen by a consultant psychologist at home on 31 March.
The deceased’s mood fluctuated and his wife rang the Crisis team in the early hours of 2 April 2017. He was seen at home at 10 am on 2 April 2017 by a nurse during which he explained how he had held a knife to his chest. During the consultation he calmed and denied strong urges to end his life. Medication was delivered later that day by a Community Support Worker who carried out no formal assessment of the deceased’s mental state.
The deceased remained anxious and outwardly stressed about an impending visit from a psychiatrist and certain domestic building works that were being done at the time.
In the morning of 3 April 2017 the deceased and his wife discussed the renovation work; he then became distressed as a result of his clothing splitting and remained anxious whilst his wife showered.
His wife subsequently discovered the deceased slumped at the foot of the stairs with a ligature fashioned from pyjamas around his neck and the newel post. He sustained fatal injuries as a result and died on 8 April 2017.
Following his death Nottinghamshire Healthcare NHS Foundation Trust prepared a Quality Improvement Plan dated 22 June 2017.
Within it were 6 recommendations which raised issues with basic healthcare practice including such fundamentals as accurate note-taking and the appropriate route to escalate concerns about a patient.

(1) The failure of the Crisis Team to ensure consistency and continuity of care for the deceased, in particular the changing personnel who visited the deceased;
(2) The failure of the Crisis Team to make accurate and prompt records of all consultations with the deceased;
(3) The failure of the Crisis Team promptly to report/escalate any matters of concern to senior members of staff so that appropriate and timely steps could be taken in relation to the management of the deceased’s care including, if necessary, hospitalisation;