UK Inquiry Tracker

William Higgleton

PFD Report Partially Responded Ref: 2016-0131

Date of Report 9 March 2016

Coroner Nadia Persaud

Coroner Area London (East)

Response Deadline est. 4 May 2016

Community health care and emergency services related deaths

Judiciary.uk Report PDF

1 of 2 responded · Over 2 years old

Sent To

Response Status

Responses 1 of 2

56-Day Deadline 4 May 2016

Over 2 years old — no identified published response

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner's Concerns

Iconsidered that Mr Higgleton's primary diagnosis was anti-social personality disorder: She confirmed that the primary treatment for this condition would be psychotherapy services confirmed however that there is a lack of service provision for psychotherapy care to be provided to persons suffering from anti-social personality disorder. The lack of service provision in this regard was confirmed byl (Assistant Director Adult Mental Health and Learning Disabilities). consider that the lack of provision of psychotherapy services to this group of patients presents a risk of future deaths occurring:

Responses

DownloadWilliam Higgleton Response

28 Apr 2016

Response received

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Dear Ms Persaud, Re: Inquest touching_upon the death of Mr William Stanley Higgleton Regulation 28 Report write in response to the Prevention of Future Deaths Report issued to North East London NHS Foundation Trust and Redbridge Clinical Commissioning Group on the 7th March 2016, following the Coroner' s inquest into the death of Mr William Stanley Higgleton. Please note that the North East London NHS Foundation Trust (NELFT) and Barking and Dagenham, Havering; Redbridge Clinical Commissioning Groups (CCGs) met on 30th March 2016 and discussed the Coroner's concerns set out in the Regulation 28 report relating to the death of William Stanley Higgleton. At the meeting, an agreement was reached to review the care pathways for the patients suffering with anti-social personality disorder; to ensure that they are supported to access the existing services in' conjunction with National Institute for Health and Social Care Excellence (NICE) guidelines It was also agreed that communication plan will be developed to ensure that the staff involved in provision of care of these patients are aware of the pathways they should follow This review will also indicate if there are any gaps in the existing provision of services, so that the appropriate action could be taken for the purposes of compliance with NICE guidelines. We will also consider how we could develop personality disorder networks locally as per NICE guidance_ The review should commence in May 2016 with the view of completing it by 30 September 2016 Please find attached report for the Coroner, which was prepared jointly by NELFT and CCG following the meeting on 30th March 2016. NELFT strives to learn from incidents and to constantly improve the service provision it provides Please do not hesitate to contact me if you require any clarification:

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Action Should Be Taken

In opinion action should be taken to prevent future deaths and believe you have the power to take such action:

Report Sections

Investigation and Inquest

On the 28lh 2015, commenced an investigation into the death of William Stanley Higgleton; The investigation concluded at the end of the Inquest on the March 2016_ The conclusion of the Inquest was a narrative conclusion: Mr Higgleton suffered anti-social personality disorder and mixed anxiety and depressive disorder: He had reported multiple overdoses in the period November 2013 to March 2015. He was assessed as high risk to self from November 2013 to July 2015. Despite the history of overdoses and the considered high risk to self; his access to medication was not limited. He did not have any support in the community from the mental health team, to assist him with compliance with medication or to assess his mental state more frequently and in his home environment On the 22nd July 2015 he was found deceased in his home address. Mr Higgleton had taken his own life by ingesting excessing amounts of medication He had taken his own life while suffering from a mental disorder:

Circumstances of the Death

Mr Higgleton had suffered from anti-social personality disorder for many years. He had also suffered from anxiety and depressive disorder for around 5 years prior to his death. He came under the care of the North East London Foundation Trust from November 2013. He was referred to the mental health team at this time as hehad taken an overdose of medication: Mr Higgleton had been seen by lin June 2014. considered the diagnosis to be mixed affective disorder: ithen saw him in October 2014_ March 2015 and July 2015_ considered the diagnosis to be anti-social personality disorder and mixed anxiety and depressive disorder: Ionfirmed that Mr Higgleton had complex needs. She did not however consider that he would fit the criteria for CPA or the Community Recovery Team. Mr Higgleton remained under the HAABIT team for 20 months, despite HAABIT being a short-term assessment team and July confirmed that throughout her period of caring for Mr Higgleton, he was considered as a long term high risk of harm to self. He had a history of taking overdoses and self-harming by cutting: He also reported in March 2015 taking monthly overdoses wth suicidal intent. confirmed that the high risk presented by Mr Higgleton had been managed through psychiatric assessments (planned every 2-3 months) , prescription of anti-depressive and anti-psychotic medication and by referral to psychotherapy services During the period of the care under NELFT, Mr Higgleton had not received any psychological therapies On the 22nd 2015 Mr Higgleton was found deceased in his bed at home. There is no evidence of any third party involvement in his death and no suspicious circumstances. The toxicology revealed excessive amounts of Citalopram_ Tramadol and Mirtazapine in his blood: The pathologist gave a cause of death of 1a multiple drug overdose