Adrian James
PFD Report
All Responded
Ref: 2024-0128
All 2 responses received
· Deadline: 2 May 2024
Coroner's Concerns (AI summary)
The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for predicting and preventing impulsive acts of self-harm.
View full coroner's concerns
1. That Adrian, despite being a complex patient with multiple psychiatric
Responses
Noted
NHS England expresses condolences and outlines its commitment to improving community mental health services nationally, but states that responding to the specific concerns raised by the coroner is the remit of the named NHS Trust. They confirm the concerns have been shared with their national Mental Health Team and Regulation 28 Working Group. (AI summary)
NHS England expresses condolences and outlines its commitment to improving community mental health services nationally, but states that responding to the specific concerns raised by the coroner is the remit of the named NHS Trust. They confirm the concerns have been shared with their national Mental Health Team and Regulation 28 Working Group. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Adrian Michael James who died on 21 June 2021
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 March 2024 concerning the death of Adrian Michael James on 21 June 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Adrian’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Adrian’s care have been listened to and reflected upon.
NHS England recognises the need to improve community mental health services to ensure high quality care and support can be accessed in a timely way. This is underpinned by commitments set out in the NHS Long Term Plan to improve community mental health, so people receive the support that they need to help them stay well. All local areas have received funding to develop and begin delivering new models of care that integrate primary care and community mental health services for adults with severe mental health problems, with care provided to at least 370,000 adults per year nationally. These models of care will give people greater choice and control over their care. They will also improve access to a range of interventions and support, including psychological therapies, physical health care, employment support, medicines management and support for self-harm and coexisting substance use, with care increasingly personalised and trauma informed. The new models should also ensure appropriate links are made with other mental health services, for example inpatient and crisis services, to ensure patients have a seamless experience of care and that their needs can be met in the most appropriate setting. It is not within NHS England’s remit to respond to the specific concerns set out by the Coroner in your Report and it is appropriate that Central and North West London NHS Foundation Trust (“the Trust”) respond to these. We understand you have also directed your Report to the Trust to respond to your concerns. NHS England has been asked to be sighted on the Trust’s response to you and will carefully consider this. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
30 April 2024
Your Report and concerns have also been shared with and considered by NHS England’s national Mental Health Team. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 March 2024 concerning the death of Adrian Michael James on 21 June 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Adrian’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Adrian’s care have been listened to and reflected upon.
NHS England recognises the need to improve community mental health services to ensure high quality care and support can be accessed in a timely way. This is underpinned by commitments set out in the NHS Long Term Plan to improve community mental health, so people receive the support that they need to help them stay well. All local areas have received funding to develop and begin delivering new models of care that integrate primary care and community mental health services for adults with severe mental health problems, with care provided to at least 370,000 adults per year nationally. These models of care will give people greater choice and control over their care. They will also improve access to a range of interventions and support, including psychological therapies, physical health care, employment support, medicines management and support for self-harm and coexisting substance use, with care increasingly personalised and trauma informed. The new models should also ensure appropriate links are made with other mental health services, for example inpatient and crisis services, to ensure patients have a seamless experience of care and that their needs can be met in the most appropriate setting. It is not within NHS England’s remit to respond to the specific concerns set out by the Coroner in your Report and it is appropriate that Central and North West London NHS Foundation Trust (“the Trust”) respond to these. We understand you have also directed your Report to the Trust to respond to your concerns. NHS England has been asked to be sighted on the Trust’s response to you and will carefully consider this. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
30 April 2024
Your Report and concerns have also been shared with and considered by NHS England’s national Mental Health Team. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Action Taken
The Trust outlines actions taken and planned, including issuing additional guidance on managing suicide risk, sharing learning with the team, updating policies, and reminding staff of the need for communication amongst professionals involved in treatment. (AI summary)
The Trust outlines actions taken and planned, including issuing additional guidance on managing suicide risk, sharing learning with the team, updating policies, and reminding staff of the need for communication amongst professionals involved in treatment. (AI summary)
View full response
Dear Professor Wilcox, Regulation 28: Report to prevent future deaths in relation to Adrian James Thank you for your Regulation 28 report dated 7 March 2024 following the inquest into the death of Adrian James. I am writing to provide Central and North West London NHS Foundation Trust (CNWL)’s response to the concerns that you raised in that report. We deeply regret the death of Mr James and the distress this has caused his family to whom we would like to extend our sincere condolences. We have listed your concerns in bold, followed by the Trust’s response:
1. That Adrian, despite being a complex patient with multiple psychiatric diagnoses and at high risk of impulsive behaviour and suicide was not seen nor assessed by a consultant either prior to starting psychological therapy or when he deteriorated. We are issuing additional guidance around managing risk of suicide in those with a diagnosis of Personality Disorder (or more commonly now known as Complex Emotional Needs) reminding staff to consider the need for assessment by a Consultant Psychiatrist. The team operates as a multidisciplinary unit. Senior clinical support and decision- making are facilitated through weekly Multidisciplinary Team (MDT) meetings, direct oversight from a Consultant Psychiatrist, and participation in the daily meetings, which are regularly attended by the team's Consultant Psychiatrist. In the event of concerns raised during the meetings, there is an opportunity to schedule an appointment with the Team Consultant Psychiatrist for further discussion. However, access to support for service users with complex emotional needs does not require an initial appointment with a psychiatrist. Trust Headquarters, 350 Euston Road, London NW1 3AX Telephone: 020 3214 5700
2. That No pro-active care was considered for Adrian whilst he was in obvious mental health crisis in the last 17 days of his life. We have shared learning on this with the team and are updating our policies accordingly.
3. That Insufficient consideration appeared to have been given to the risk of impulsive suicide with instead assessment focussing on his denial of increased active suicidal intent. This is an ongoing area of focus. We are part of interagency Suicide Prevention group for Kensington, Chelsea and Westminster. In addition, we recently held a Learning session entitled - Suicide Prevention Part 1: Understanding Suicide. We are also piloting a new way of caring for service users in South Westminster (“Open Dialogue”) with the overall goal to enter into discussion and communication with different sources to ensure increased participation in the safety and treatment of the service user.
4. That no follow up call or assessment was made to Adrian when his treatment session was interrupted by police attendance, and the treatment call was cut off. We are reviewing our guidance on this and will ensure staff are clear on action to be taken.
5. That there were inadequate communications between the PCN MDT and those providing the psychological treatment. We are reminding staff of the need for consistent and adequate communication amongst professionals involved in treatment. The team members in both of the teams above attend weekly meetings where the importance of this is constantly emphasised. Thank you for raising these concerns. I hope that this response provides sufficient assurance that CNWL has taken them seriously, has acted following the death of Mr James and has accepted the points raised and continues to work to improve the service we provide. Should you have any further questions, please do not hesitate to contact me.
1. That Adrian, despite being a complex patient with multiple psychiatric diagnoses and at high risk of impulsive behaviour and suicide was not seen nor assessed by a consultant either prior to starting psychological therapy or when he deteriorated. We are issuing additional guidance around managing risk of suicide in those with a diagnosis of Personality Disorder (or more commonly now known as Complex Emotional Needs) reminding staff to consider the need for assessment by a Consultant Psychiatrist. The team operates as a multidisciplinary unit. Senior clinical support and decision- making are facilitated through weekly Multidisciplinary Team (MDT) meetings, direct oversight from a Consultant Psychiatrist, and participation in the daily meetings, which are regularly attended by the team's Consultant Psychiatrist. In the event of concerns raised during the meetings, there is an opportunity to schedule an appointment with the Team Consultant Psychiatrist for further discussion. However, access to support for service users with complex emotional needs does not require an initial appointment with a psychiatrist. Trust Headquarters, 350 Euston Road, London NW1 3AX Telephone: 020 3214 5700
2. That No pro-active care was considered for Adrian whilst he was in obvious mental health crisis in the last 17 days of his life. We have shared learning on this with the team and are updating our policies accordingly.
3. That Insufficient consideration appeared to have been given to the risk of impulsive suicide with instead assessment focussing on his denial of increased active suicidal intent. This is an ongoing area of focus. We are part of interagency Suicide Prevention group for Kensington, Chelsea and Westminster. In addition, we recently held a Learning session entitled - Suicide Prevention Part 1: Understanding Suicide. We are also piloting a new way of caring for service users in South Westminster (“Open Dialogue”) with the overall goal to enter into discussion and communication with different sources to ensure increased participation in the safety and treatment of the service user.
4. That no follow up call or assessment was made to Adrian when his treatment session was interrupted by police attendance, and the treatment call was cut off. We are reviewing our guidance on this and will ensure staff are clear on action to be taken.
5. That there were inadequate communications between the PCN MDT and those providing the psychological treatment. We are reminding staff of the need for consistent and adequate communication amongst professionals involved in treatment. The team members in both of the teams above attend weekly meetings where the importance of this is constantly emphasised. Thank you for raising these concerns. I hope that this response provides sufficient assurance that CNWL has taken them seriously, has acted following the death of Mr James and has accepted the points raised and continues to work to improve the service we provide. Should you have any further questions, please do not hesitate to contact me.
Sent To
- Central and North West London NHS Foundation Trust
- NHS England
Response Status
Linked responses
2 of 2
56-Day Deadline
2 May 2024
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
Report Sections
Investigation and Inquest
Between 5th and 6th March 2024, evidence was heard before the Coroner touching the death of Mr Adrian Michael James. He had died on the 21st June 2021, aged 39 years at St Mary’s Hospital, Praed Street, London, following dropping from height.
Medical Cause of Death
1 a Head Injury b Fall from height
How, when, where and the deceased came by his death:
On 25th June 2021 at approximately 15:30, Adrian dropped from the 4th floor of the block of flats in which he lived. He sustained a serious head injury which rendered him immediately unconscious and caused his death, despite extensive resuscitation at St Mary’s Hospital at 16:39 hours.
Adrian suffered with Antisocial and Emotionally Unstable Personality Disorders, complicated by depression and substance misuse. He had attempted to take his own life on multiple occasions. He had been more settled in recent years, but his suicidal risk remained high.
In the last months of his life, he was under the care of community mental health services, primary care network (PCN) and was being treated with structured psychological support.
From April 2021, building works at his residence exacerbated his paranoia and from 8th June 2021 this manifested as repeated crisis contact with emergency and psychiatric services-more than 25 occasions up to his death from 8th June 2021.
Twice during this time, he was detained on section 136 and then discharged following Mental Health Act Assessment to his usual community care.
His care was reviewed daily from 9th June 2021 in PCN meetings, and he was supported by crisis contact, including a home visit when he failed to respond to welfare check calls.
On 25th June 2021 he was engaging in a structured psychological support session with a psychiatrist, when police attended to check on him following concerns raised about suicidality from a member of the public.
Shortly after police left, he was heard to be screaming and then seen to be hanging off the balcony on the 4th floor of his block of flats. He was seen to let go and fall to his death.
At all assessments in the last weeks of his life he had presented with paranoid ideation and with a background risk of suicide, but no increased intent to take his own life.
It is likely that his death was due to an impulsive act on his part whilst suffering distress due to paranoia as part of his illness.
Conclusion of the Coroner as to the death:
He took his own life whilst suffering severe and enduring mental illness Extensive evidence was taken during the inquest from multiple live witnesses, written statements, and exhibited reports. Of relevance to this report in addition to the findings above, which I do not repeat:
Adrian’s death as an impulsive act, was not easily predicable and preventable and the emotional variability with which he presented made it difficult for him to be assessed, as he could switch quickly from an agitated state to one in which he was relatively calm. At all times he retained capacity.
At no point was he sectionable under the Mental Health Act in the last 2 weeks of his life, although he had been detained by Police twice under section 136.
He accepted treatment through community health services and used crisis interventions for support which are likely to have been roughly equivalent to services that he would have received had he been supported by the Home Treatment Team or equivalent during the material time, as this would likely have been by phone call as this was during Covid lockdown.
However, despite the sheer number of contacts no pro-active treatment past his usual care and response to crisis calls was offered. Note that in the last 14 days of his life he had received 2 Mental Health Act Assessments after s136 detention, been seen by Liaison Psychiatry at Chelsea and Westminster Hospital and made countless calls for support. Despite him continually denying an active suicidal intent, I remain concerned that whilst albeit there were multiple reviews at MDTs insufficient consideration was given to his risk of impulsive suicide and the possibility of mitigating this risk by a pro-active rather than reactive care package. The evidence of distress caused by paranoia was there. It may be that a more structured support plan would have helped to contain his distress between his fortnightly sessions of structured psychological therapy.
Despite the obvious deterioration in his paranoia there was no evidence heard that medication was actively considered to help alleviate, this except in hindsight.
Home Treatment Team Care (First Response Team) had been considered on 15th June 2021 as part of his assessment by the AMHP, but there is no evidence in his notes from CNWL, that this was considered after this time, despite further crisis contact.
Adrian was undoubtedly a complex patient to treat, but when he deteriorated, his treatment sessions were left with the specialist doctor in training and he did not receive assessment by the psychiatric consultant in the community, who in fact never met him, either before he started the structured psychological treatment or when he deteriorated.
When the police interrupted his last treatment session, the psychiatrist did not try and call Adrian back to ask how he was and to re-assess his risk, despite the number of crisis contacts, his paranoia with associated distress, his known high background risk of suicide, his risk of impulsivity, emotional instability, and his very recent s136 detentions etc. The doctor discussed what had happened with the team and it was decided to wait and see if police contacted psychiatric services rather than re contact the patient, taking reassurance from police presence, despite police officers wishing to talk to doctor and requesting telephone contact numbers but being unable to secure these before the signal on the call between police and psychiatrist failed. Adrian’s phone number was available to the doctor and the PCN team. Police officers are not mental health clinicians.
The court found that the lack of re contact with Adrian by the psychiatrist after the treatment session was interrupted, was a failure in care.
Police did try and call SPA but hung up after being told that they were 4th in the queue as they expected a wait of hours before being answered at that time.
Police did arrange a follow up visit for Adrian by the police night shift. Adrian had declined LAS attendance and refused a lift from the officers to St Thomas’s Hospital.
However, Adrian had come from the balcony about an hour after the police left.
Police systems have now changed, and Adrian would now be checked by health care rather than police. SPA answer times have also improved.
It was not until the final witness, who was from the PCN, did the level of consideration and care being given by the PCN become apparent. Both the treating consultant and the PCN Service Lead noted the lack of formal regular input from the treating consultant’s team to the PCN MDT.
Whilst it could not be said that the matters outlined above contributed to the death on the facts of this case, concerns remain.
This report has also been sent to NHS England, so that the lessons learned from this death may be applied to mental health care services. Matters of Concern
1. That Adrian, despite being a complex patient with multiple psychiatric diagnoses and at high risk of impulsive behaviour and suicide was not seen nor assessed by a consultant either prior to starting psychological therapy or when he deteriorated.
2. That no pro-active care was considered for Adrian whilst he was in obvious mental health crisis in the last 17 days of his life.
3. That insufficient consideration appeared to have been given to the risk of impulsive suicide with instead assessment focussing on his denial of increased active suicidal intent.
4. That no follow up call or assessment was made to Adrian when his treatment session was interrupted by police attendence, and the treatment call was cut off.
5. That there were inadequate communications between the PCN MDT and those providing the psychological treatment.
Medical Cause of Death
1 a Head Injury b Fall from height
How, when, where and the deceased came by his death:
On 25th June 2021 at approximately 15:30, Adrian dropped from the 4th floor of the block of flats in which he lived. He sustained a serious head injury which rendered him immediately unconscious and caused his death, despite extensive resuscitation at St Mary’s Hospital at 16:39 hours.
Adrian suffered with Antisocial and Emotionally Unstable Personality Disorders, complicated by depression and substance misuse. He had attempted to take his own life on multiple occasions. He had been more settled in recent years, but his suicidal risk remained high.
In the last months of his life, he was under the care of community mental health services, primary care network (PCN) and was being treated with structured psychological support.
From April 2021, building works at his residence exacerbated his paranoia and from 8th June 2021 this manifested as repeated crisis contact with emergency and psychiatric services-more than 25 occasions up to his death from 8th June 2021.
Twice during this time, he was detained on section 136 and then discharged following Mental Health Act Assessment to his usual community care.
His care was reviewed daily from 9th June 2021 in PCN meetings, and he was supported by crisis contact, including a home visit when he failed to respond to welfare check calls.
On 25th June 2021 he was engaging in a structured psychological support session with a psychiatrist, when police attended to check on him following concerns raised about suicidality from a member of the public.
Shortly after police left, he was heard to be screaming and then seen to be hanging off the balcony on the 4th floor of his block of flats. He was seen to let go and fall to his death.
At all assessments in the last weeks of his life he had presented with paranoid ideation and with a background risk of suicide, but no increased intent to take his own life.
It is likely that his death was due to an impulsive act on his part whilst suffering distress due to paranoia as part of his illness.
Conclusion of the Coroner as to the death:
He took his own life whilst suffering severe and enduring mental illness Extensive evidence was taken during the inquest from multiple live witnesses, written statements, and exhibited reports. Of relevance to this report in addition to the findings above, which I do not repeat:
Adrian’s death as an impulsive act, was not easily predicable and preventable and the emotional variability with which he presented made it difficult for him to be assessed, as he could switch quickly from an agitated state to one in which he was relatively calm. At all times he retained capacity.
At no point was he sectionable under the Mental Health Act in the last 2 weeks of his life, although he had been detained by Police twice under section 136.
He accepted treatment through community health services and used crisis interventions for support which are likely to have been roughly equivalent to services that he would have received had he been supported by the Home Treatment Team or equivalent during the material time, as this would likely have been by phone call as this was during Covid lockdown.
However, despite the sheer number of contacts no pro-active treatment past his usual care and response to crisis calls was offered. Note that in the last 14 days of his life he had received 2 Mental Health Act Assessments after s136 detention, been seen by Liaison Psychiatry at Chelsea and Westminster Hospital and made countless calls for support. Despite him continually denying an active suicidal intent, I remain concerned that whilst albeit there were multiple reviews at MDTs insufficient consideration was given to his risk of impulsive suicide and the possibility of mitigating this risk by a pro-active rather than reactive care package. The evidence of distress caused by paranoia was there. It may be that a more structured support plan would have helped to contain his distress between his fortnightly sessions of structured psychological therapy.
Despite the obvious deterioration in his paranoia there was no evidence heard that medication was actively considered to help alleviate, this except in hindsight.
Home Treatment Team Care (First Response Team) had been considered on 15th June 2021 as part of his assessment by the AMHP, but there is no evidence in his notes from CNWL, that this was considered after this time, despite further crisis contact.
Adrian was undoubtedly a complex patient to treat, but when he deteriorated, his treatment sessions were left with the specialist doctor in training and he did not receive assessment by the psychiatric consultant in the community, who in fact never met him, either before he started the structured psychological treatment or when he deteriorated.
When the police interrupted his last treatment session, the psychiatrist did not try and call Adrian back to ask how he was and to re-assess his risk, despite the number of crisis contacts, his paranoia with associated distress, his known high background risk of suicide, his risk of impulsivity, emotional instability, and his very recent s136 detentions etc. The doctor discussed what had happened with the team and it was decided to wait and see if police contacted psychiatric services rather than re contact the patient, taking reassurance from police presence, despite police officers wishing to talk to doctor and requesting telephone contact numbers but being unable to secure these before the signal on the call between police and psychiatrist failed. Adrian’s phone number was available to the doctor and the PCN team. Police officers are not mental health clinicians.
The court found that the lack of re contact with Adrian by the psychiatrist after the treatment session was interrupted, was a failure in care.
Police did try and call SPA but hung up after being told that they were 4th in the queue as they expected a wait of hours before being answered at that time.
Police did arrange a follow up visit for Adrian by the police night shift. Adrian had declined LAS attendance and refused a lift from the officers to St Thomas’s Hospital.
However, Adrian had come from the balcony about an hour after the police left.
Police systems have now changed, and Adrian would now be checked by health care rather than police. SPA answer times have also improved.
It was not until the final witness, who was from the PCN, did the level of consideration and care being given by the PCN become apparent. Both the treating consultant and the PCN Service Lead noted the lack of formal regular input from the treating consultant’s team to the PCN MDT.
Whilst it could not be said that the matters outlined above contributed to the death on the facts of this case, concerns remain.
This report has also been sent to NHS England, so that the lessons learned from this death may be applied to mental health care services. Matters of Concern
1. That Adrian, despite being a complex patient with multiple psychiatric diagnoses and at high risk of impulsive behaviour and suicide was not seen nor assessed by a consultant either prior to starting psychological therapy or when he deteriorated.
2. That no pro-active care was considered for Adrian whilst he was in obvious mental health crisis in the last 17 days of his life.
3. That insufficient consideration appeared to have been given to the risk of impulsive suicide with instead assessment focussing on his denial of increased active suicidal intent.
4. That no follow up call or assessment was made to Adrian when his treatment session was interrupted by police attendence, and the treatment call was cut off.
5. That there were inadequate communications between the PCN MDT and those providing the psychological treatment.
Action Should Be Taken
It is for each addressee to respond to matters relevant to them.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.