Dr Malcolm Dixon · Prevention of Future Deaths report

On 11th March 2020, Alison Mutch OBE, Senior Coroner for Greater Manchester (South), opened an inquest into the death of Dr Malcolm Dixon who died on 29th December 2019 at the Priory Hospital, Altrincham. The investigation concluded at the end of the inquest which I heard between 1st and 5th November 2021.

The consultant pathologist who undertook the post mortem examination determined Dr Dixon died as a consequence of:

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At the end of the inquest, I recorded a narrative conclusion that Dr Dixon took his own life whilst his state of mind was adversely affected by a severe depressive illness.

During autumn of 2019, Dr Dixon became unwell with what was later diagnosed as a severe depressive illness.

Dr Dixon was admitted to the Priory Hospital, Altrincham as an informal, voluntary patient and was treated by means of medication, observation by and interaction with staff, and participation in activities sessions.

Dr Dixon died on 29th December 2019 at the hospital, as a consequence of ████████

This was an impulsive act undertaken within the context of an episode of severe mental illness.

The Court heard it was likely that an observation chart, designed to record regular observations, had been pre-populated by a staff member to show when observations were intended to be taken as opposed to recording when they actually took place. Additionally, the Court heard that the automatic timings generated by the electronic care record system in use at the Priory could be over-written manually, thus leading to inaccurate times being recorded in the records. The following concerns arise from the above:

1. Given the particular importance of documented observations being taken at specific intervals on mental health wards, it is a matter of concern that standardised observation charts (together with accompanying standard rules as to how they should be completed) are not in use across these settings both in the NHS and private sectors;

2. For similar reasons, it is a matter of concern that automatic time-stamps generated by electronic care records systems can be overwritten by users without the corresponding record showing clearly that this has happened, whilst also recording of the actual time an entry has been made.

3. It is a matter of concern that, where record keeping on a ward is undertaken by unregistered staff such as Nursing Assistants and Healthcare Assistants, such individuals are not subject to professional requirements in respect of documentation, such as those which exist for doctors and nurses.