Unexpected deaths double and suicide risks increase

Posted on February 23, 2017

The BBC recently led with a news story that the number of unexpected patient deaths (including deaths by suicide, neglect and misadventure) reported by England’s mental health trusts has risen by almost 50% in three years.

Mental health care provision remains severely under-funded on both a local and national scale. The situation will only get worse in light of the threatened decommissioning of services as part of the ongoing NHS funding review. Too many people in need are left facing significant delays in accessing assessment and treatment sessions forcing many to reach crisis point and even when individuals managed to access help issues can still arise.

We are frequently instructed to investigate cases where someone in need has accessed the relevant service, but failures in care continue to result in avoidable suicides.

In one recent case our client instructed us to investigate her son’s suicide following his discharge from long term detention under the Mental Health Act. The deceased was discharged from The Royal Oldham Hospital. Sadly the deceased found that due to the lack of structure and support following his discharge into the community he was unable to cope, he was unable to access help and he ultimately committed suicide approximately four months later.

As part of our investigation we secured independent expert evidence which identified 22 separate breaches of duty of care.

These breaches included a failure to undertake a formal Section 117 discharge planning meeting, a failure to involve family and carers in the discharge process, a failure to use extended leave to assess the deceased’s ability to function independently, a failure to discuss the proposed conditions of the Community Treatment Order with family and carers, failures to act upon breaches of the terms of the CTO following discharge, and a failure to monitor the deceased following discharge including a failure to provide sufficient outpatient consultant psychiatric appointments and several missed opportunities to assess the deceased’s mental health state and medication compliance.

At a more fundamental level the Trust failed to register the deceased with a GP and ensure he knew how to access a local pharmacy for his medication. The expert also concluded that, but for the significant number of breaches of duty of care, the deceased would not have committed suicide.

The outcome of the claim was a recovery of damages for the deceased’s pain, suffering and lost amenity along with reimbursement of the funeral and memorial costs.

In addition we successfully argued that the Trust had breached its operational obligation under Article 2 of the Convention for the Protection of Human Rights and Fundamental Freedoms. The deceased, his mother and his grandmother struggled to cope with his difficulties in the period between discharge and death, and his mother and grandmother experienced immense distress in coming to terms with the numerous failures of care and the aftermath of his tragic death.

"People access mental health services for a multitude of reasons. The services are overwhelmed and are likely to be undermined further with impending funding cuts. Where an individual has successfully accessed the service it is crucial that a good standard of care is provided, particular where the individual’s needs are so great that failure can result in their avoidable suicide," said medical negligence solicitor Kenneth Lees.

"Whilst we recovered damages for the deceased’s estate and his family in these circumstance nothing will ever make up for the tragic loss of a son and grandson. Unless mental health services receive an appropriate level of funding such cases will arise more and more frequently," he added.

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