UK Inquiry Tracker

Rohan Fitzsimons

PFD Report Partially Responded Ref: 2016-0288

Date of Report 7 August 2016

Coroner Peter Harrowing

Coroner Area Avon

Response Deadline ✓ from report 3 October 2016

Community health care and emergency services related deaths

Judiciary.uk Report PDF

1 of 3 responded · Over 2 years old

Sent To

Response Status

Responses 1 of 3

56-Day Deadline 3 Oct 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

Coroners Concerns

_ The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject to the funding provided by the Bristol Clinical Commissioning Group (CCG) (2) The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred_ (3) In the case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a could lead to an individual taking their own life before the assessment was performed and a bed was made available (4) The CCG should review urgently its commissioning of in-patient mental health beds s0 as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment; The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available: If a person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period to a lack of beds.

Responses

Avon and Wiltshire NHS Trust

6 Oct 2016

Response received

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Dear Dr Harrowing am writing in response to the Prevention of Future Death report you issued to this Trust following the inquest into the death of Rohan Fitzsimons The work to respond to the improvements you have required is being led by Associate Director of Nursing (Inpatient and Community) and Associate Director for Statutory Delivery. The Trust remains committed to the Principle of Recovery and the role positive risk taking has in risk assessment and care planning, as highlighted in the Department of Health Best Practice on Risk Assessment in Mental Health Services; however it recognises the need for explicit guidance for clinical staff. The joint protocol for the Management of Missing Persons and Absent Without Leave has been extensively reviewed internally by the Trust: We have identified proposals to simplify this document and to clarify the decision making pathways in relation to people deemed to be at low or medium risk who fail to return from leave at the specified time, to ensure that the procedures are flexible and decisions are based on proportionate responses to each individual's needs and risks It is also vital that these revised procedures are practicable both for AWP staff and for the Police, as these are jointly agreed multi-agency procedures. We therefore will be consulting with key inpatient clinicians and the Police Liaison officers for Avon & Somerset and Wiltshire forces this month on the proposed changes to the joint protocol, with the intention to ratify agreed changes by the beginning of November 2016. The existing policy will remain in place until this work is complete, to ensure the continued collaboration with the local police forces is maintained during this period. Once ratified, we will ensure that the revised joint protocol for the Management of Missing Persons and Absent without Leave is disseminated and understood by ward based staff via a training programme delivered by ward managers_ In relation to the Section 17 procedure, this has been amended to be explicit that a Mental State examination must be undertaken by a registered practitioner , and that leave must be Continued_ Acting Chair Trust Headquarters Chief Executive Jenner House, Langley Park, Chippenham, SN15 1GG Hayley Richards 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell US otherwise Flax

authorised by that individual prior to the commencement of any leave: Additionally, a Standard template to record this information has been developed, and forms part of the amended procedure_ The revised procedure and standard template was subject to consultation with key inpatient staff to ensure that the proposals were considered practical for use by front line staff, and was ratified by the Trust Director of Nursing and Quality: The revised procedure is being currently disseminated to staff through Trust Modern Matrons and Ward Managers_ It is also recognised that merely having amended procedures in place and ensuring staff are informed and trained in the use of the procedures, does not in itself ensure that the changes in practice set out in the procedures are consistently applied in all inpatient wards in the Trust Therefore; to provide the necessary assurance that practice is safe and consistently to the standards set out in amended procedures, a regular audit of practice will be undertaken in relation to review of risks for patients who return late from s17 Leave; and of checks and authorisation prior to episodes of leave by registered nurses will be undertaken every Quarter 2016/2017 . In addition continuing compliance with MHA related standards, including those for s17 Leave, will be subject to on-going dip sampling audit and feedback by a restructured Trust Mental Health Act Administration team as part of the MHA audit schedule for all wards that will be introduced in 2017/2018 to providing on-going assurance_ If you require further information, please do not hesitate to let me know.

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action

Report Sections

Investigation and Inquest

On 8th December 2015 commenced an investigation into death of Mr. Rohan Fitzsimons age 21 years. The investigation concluded at the end of the inquest on 20th July 2016. The conclusion of the jury was that the medical cause of death was I(a) Multiple Injuries the conclusion as to the death was that of Suicide.

Circumstances of the Death

From around 2014 concerns were raised with regard to behaviour of the Deceased and in October 2014 he was admitted to hospital in Hertfordshire under S.2 Mental Health Act 1983 On 7th March 2015 he was again admitted to hospital in Hertfordshire under S.2 Mental Health Act 1983 and at that time a diagnosis of drug-induced psychosis was made. Following discharge from hospital on Ist April 2015 he was referred to the Bristol Crisis Team to support his transition from the ward to his home in Bristol. He was later transferred to the care of the Early Intervention Team He was accepting of medication and agreed to the input of a support worker: However; towards the end of April 2015 he began missing appointments with the community team; His family became concerned with regard to his obtaining accommodation and his finances. In July 2015 his family thought he had stopped taking his medication and was displaying paranoid behaviour When they were unable to contact him they reported him as a missing person: The community team saw him the following day and he was noted to be unwell, dishevelled, describing delusional ideas and neglecting himself. Engagement with the community team over the following few weeks was sporadic and there was evidence the Deceased's mental state was continuing to decline. In October 2015 it was discovered he had caused significant damage to his property and was facing eviction. On 18th October 2015 the Deceased was assessed by the Crisis Team due to concerns over his mental state: The following day, the 19th October 2015, he was seen by the registered mental health nurse from the Early Intervention Team together with a consultant psychiatrist as a result of which it was determined he met the criteria for a Mental Health Act Assessment This was discussed with the Approved Mental Health practitioner who advised there were no beds available: The Inquest heard evidence that since there was no bed available the Mental Health Act Assessment was not carried out and that is was usual practice not to carry out such an assessment unless and until a bed was available On 23rd October 2015 a bed had become available and the Deceased underwent a Mental Health Act Assessment and was detained under S.2 of the Act on the Silver Birch and the and the July

Unit; Callington Road Hospital. The Deceased was diagnosed with schizophrenia and was prescribed antipsychotic medication. Whilst on the Silver Birch Unit concerns were raised that the Deceased may not have been taking his medication and he displayed violent and aggressive behaviour: Owing to this behaviour it was necessary to transfer him to the Hazel Unit and intensive care facility at Callington Road Hospital He was transferred back to the Silver Birch Unit on 9th November 2015_ Prior to the expiry of the S.2 period of detention the Deceased was further detained under S.3 of the Act Following his return to the Silver Birch Unit the Deceased became more settled and he was granted leave in accordance with S.17 Mental Health Act 1983 on a staged basis. The Ieave periods progressed well until he was allowed unescorted community leave twice daily for one hour: On 23rd November 2015 the Deceased was late returning from leave However; he attended a Police station in Bristol and contacted the Silver Birch Unit to advise them he would be late_ No concerns were raised with regard to this late return and on 24th November 2014 it was agreed he could have unescorted leave twice daily for a period of two hours on each occasion All of the staff from the Silver Birch Unit who gave evidence stated that throughout his time at the hospital the Deceased had never indicated he had thoughts of self-harm or an intention to take his own life_ On 25th November 2015 he was signed out from the Unit at around 11:00 a.m: for his two hour period of unescorted leave. At around 15.00 hours the Police telephoned the Unit to advise that the Deceased had been seen to jump from the Clifton Suspension Bridge at around 12.30 hours had been fatally injured. The Deceased was pronounced dead at 14.42 hours on 25th November 2015 at The Portway, Bristol