The inquest into the death of Carl Thompson was heard by HM Assistant Coroner Anna Morris KC, assisted by a jury, over the course of five days.
Carl Thompson was a well-respected man who would do anything for his two daughters. He enjoyed the support of his family, many of whom lived close to his home.
In 2015, Carl received a diagnosis of paranoid schizophrenia and had periods of treatment as a hospital inpatient and in the community. In December 2021, Carl’s daughter reported that he was hearing voices and he was admitted to the Arden Ward, Stepping Hill Hospital, where he was detained under s.3 of the Mental Health Act.
At the time of his death on the 9th March 2022, Carl was on s.17 Mental Health Act (MHA) leave from the Arden Ward.
Carl had been granted leave by his Responsible Clinician on the 4th March which commenced on the 7th March. He was granted five days overnight leave and should have returned to the ward on the 11th March.
The jury made the following findings in relation to the circumstances of Carl’s death:
Carl Thompson was found unresponsive in the bedroom of his house at 01:00 by his daughter on 10th March 2022. Ambulance staff attended at 01:39 and declared him deceased as a result of a drug overdose. Mr Thompson had last been observed to be alive before 9:30pm on the evening of 9th March 2022, when he was thought to be in a deep sleep, observed by his daughter. Due to the post mortem condition of the deceased upon being found, it is likely that he died on the night of 9th
March 2022. Mr Thompson’s death was probably contributed to by a failure of producing and regularly updating adequate risk assessments in relation to the planning of his section 17 leave and updating them following reported family concerns. In addition, it is possible that Carl’s death was contributed to by a failure of both the hospital ward staff and the Community Mental Health Team. The response and lack of escalation following family concerns by ward staff was inadequate. Further to this, it was a failure by the Community Mental Health Team practitioner who assessed Carl via telephone on 9th March 2022. when in fact this should have been carried out face to face.
A number of concerns had been highlighted by the Coroner and were addressed by way of a Regulation 28 report to the Head of Patient Safety of Pennine Care NHS Foundation Trust. A Regulation 28 report is released by a Coroner at the conclusion of an inquest with the aim of preventing future deaths as a result of the same failings.
The Coroner was concerned that the jury had found that the risk assessments and risk planning for Carl’s s.17 leave in March 2022 was inadequate. Nor was this issue addressed in the Trusts’ internal investigation or any evidence provided that there have been reflections or changes following Carl’s death.
The Trust’s own internal review found that whilst Carl was on leave from the 7th March, the clinical team were made aware of an increase in Carl’s risk factors when contacted by his mother, who outlined her concerns. This represented a missed opportunity for the clinical team to understand how several factors may be combining to increase the risk for Carl, including his use of non-prescription medication and illicit substance misuse.
The clinical team could have sought to understand these risk factors through direct contact with Carl. Following such direct contact, consultation could have been sought with others within a legal framework to ask Carl to return to the ward with support from services or family. The nursing team could have escalated this information.
A risk to Carl’s physical health was present especially in view of research and evidence for substance misusers starting to use again after periods of abstaining.
The Coroner commented further concerns surrounding the 9th March, and that Carl should have been seen face to face by the Community Mental Health Team (CMHT), in line with Trust Policy. Instead he only received a telephone call from a duty worker who had never met him.
Prior to his commencing leave on the 7th March, Carl had not been allocated a CMHT Care Coordinator, despite being an inpatient since 31st December 2021, over 3 months.
Despite the Trust Review having identified a number of missed opportunities, the trust action plan, which contained six action points was still “in progress”. The Trust were not able to identify a single action point that had been completed to date.
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