UK Inquiry Tracker

Billie Lord

PFD Report All Responded Ref: 2018-0338

Date of Report 1 November 2018

Coroner Thomas Osborne

Coroner Area Milton Keynes

Response Deadline ✓ from report 27 December 2018

Suicide (from 2015)

Judiciary.uk Report PDF

All 1 response received · Deadline: 27 Dec 2018

Sent To

Milton Keynes Clinical Commissioning Group

Response Status

Responses 1 of 1

56-Day Deadline 27 Dec 2018

All responses received

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

The MATTERS OF CONCERNS are as follows: During the course of the evidence I was informed by an independent expert that it is recognised that patients admitted to an in-patient mental health facility, such as the Campbell Centre, should be cared for in single rooms and that three bedded dormitory accommodation is inappropriate since in this particular case it added to the level of stress suffered by the patient. Consideration should be given to a review of the accommodation provided at the Campbell Centre, and whether alterations can be carried out to bring the accommodation up to modern standards as recommended by the Royal College of Psychiatrists.

Responses

Milton Keynes CCG

25 Jan 2019

Response received

View full response

Dear Ms Toms, Regulation 28 Response Billie Johnathan Lord (BJL) Who Died on 11th 2017 am writing in response to your Regulation Report dated 1" November 2018 following the death of Billie Johnathan Lord on 11th July 2017 Thank you for inviting comments Milton Keynes CCG and please accept our sincere apologies for the delay in responding Unfortunately, this report was misplaced during a change in personnel: Your Report requests specific feedback relating to the Campbell Centre and its suitability as a Mental Health Inpatient facility_ can confirm that CNWL Mental Health Trust informed the CCG on 31 December 2018 that are commissioning a study to assess the feasibility of creating a new inpatient campus in Miiton Keynes: The outline proposal will bring together acute wards, older adult wards and rehabilitation services This will allow the Clinical Model associated with all services to be redesigned within a fit for purpose Unit for modern healthcare delivery; The CCG offers its full support to this significant initiative first meeting with planners is scheduled for 28h January: In the meantime, the service always endeavours to keep patients safe by making all reasonable adjustments for those deemed at risk, such as intermittent or continuous observations following a thorough Risk Assessment. Notwithstanding this; even within current constraints, the informal feedback CNWL received from the Care Quality Commission following an unannounced visit on 16" January 2019 was positive, particularly with regard to the excellent compassionate care they observed. In addition, MKCCGs Mental Health Commissioner and Quality Team members regularly meet with CNWL to gain assurance regarding all aspects of patient safety and the effectiveness of related services and pathways as well as to monitor progress against action plans for Serious Incidents and other areas requiring improvement trust that this provides you with the appropriate information relating to this case and assurance regarding the development of Mental Health provision in Milton Keynes.

Action Should Be Taken

7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th December 2018. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mr Lord Central North West London NHS Foundation Trust I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Tom OSBORNE Senior Coroner for Milton Keynes Dated: 01 November 2018

Report Sections

Investigation and Inquest

On 11/07/2017 I commenced an investigation into the death of Billie Johnathan LORD aged 26. The investigation concluded at the end of the inquest on 26th October 2018. The conclusion of the inquest was a narrative conclusion as follows: Billie Lord died from suicide whilst suffering from psychosis. He suffered from autism and a psychotic illness caused by the use of non-prescription drugs including cannabis. He was referred to the Milton Keynes Crisis team and came under the care of the Acute Home Treatment Team who saw him daily from 5th July 2017. On the 9th July 2017 he was admitted to the Campbell Centre in Milton Keynes as a voluntary patient after being arrested for an assault upon his mother. He was assessed and monitored by intermittent 15 minute observations on Hazel Ward until he absconded at 04.30am on 11th July 2017 by breaking a window with a toilet that he wrenched from the wall. He climbed onto the railway line at Denbigh Hall and ran into the path of a high speed train at 08.40 and died from his resulting injuries.

Circumstances of the Death

See Narrative conclusion above.

Inquest Conclusion

Billie Lord died from suicide whilst suffering from psychosis. He suffered from autism and a psychotic illness caused by the use of non-prescription drugs including cannabis. He was referred to the Milton Keynes Crisis team and came under the care of the Acute Home Treatment Team who saw him daily from 5th July 2017. On the 9th July 2017 he was admitted to the Campbell Centre in Milton Keynes as a voluntary patient after being arrested for an assault upon his mother. He was assessed and monitored by intermittent 15 minute observations on Hazel Ward until he absconded at 04.30am on 11th July 2017 by breaking a window with a toilet that he wrenched from the wall. He climbed onto the railway line at Denbigh Hall and ran into the path of a high speed train at 08.40 and died from his resulting injuries.