UK Inquiry Tracker

Astonn Mitchell-Male

PFD Report Historic (No Identified Response) Ref: 2018-0248

Date of Report 26 July 2018

Coroner Lisa Hashmi

Coroner Area Manchester (North)

Response Deadline est. 19 November 2018

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by poor and non-existent record keeping, undermining patient safety.

View full coroner's concerns

self the living They They

1.0 There is no policy in existence within the Trust to address the process of patient medication monitoringlcompliance and the triangulation of corroborative information , particularly within the community setting: There was evidence t0 show that record keeping was poor and at some points non-existent Records are a vital form of communication about the patients condition and care provision: As such, poor compliance goes to the of patient safety_

Sent To

Pennine Care NHS Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 19 Nov 2018

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

On the 11th November 2016 commenced an investigation into the death of Astonn Mitchell-Male: The investigation was concluded by way of jury inquest on the 25"h July 2018.

Circumstances of the Death

Mr Mitchell-Male was known to suffer from SchizophrenialPsychosis and had been under the care of Psychiatric services for a number of years_ He had a history of attempts at harm, non-compliance with medication, substance misuse and tendency to self-medicate He had also come into contact with criminal justice system. At the time of his death he was within the community in supported accommodation and had a care CO-ordinator. Between August and October 2016 his mentai health showed signs of deterioration, resulting in periods of detention under the Mental Health Act (S.136, S.135 and S.2). On the 31" October 2016 police were contacted at around 21:14 by the on-call Support Worker with concern for welfare (based on Mr Mitchell-Male's mental health issues) and a noise complaint (shouting and noise having been heard coming from Mr Mitchell-Male's first floor flat by another resident): In light of the mental health element and concern for welfare, the call was graded as requiring allocation within 40 minutes and attendance in the hour. The ambulance service was asked to attend:, Both the police and ambulance were delayed. When police arrived at around 23.05, there was no sign of noiseldisturbance. were unable to gain entry to Mr Mitchell-Male's accommodation. checked the perimeter of the property, knocked on the ground floor windows and 'buzzed' the door bells There was no response. Police left a short time later and the ambulance was cancelled On the 1"t November 2016 Mr Mitchell-Male's mother discovered a voicemail that had been left by her son the night before at around 20.52. He was clearly in distress She contacted police and arranged to meet up with a police officer at Mr Mitchell-Male's address_ Upon entering the flat at around 09.20, Mr Mitchell-Male was found deceased with multiple stablincise injuries which were the direct cause of his death: The jury found that Mr Mitchell-Male: died from multiple self-inflicted stab and incise wounds on or around the evening of 31.10.16 due to deterioration of his mental state ._.' [sic] & that care provision by the mental health service, police and supported accommodation had been lacking, inadequate andlor insufficient:

Action Should Be Taken

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

Copies Sent To

Mr Mitchell