Michael Vukovic
PFD Report
All Responded
Ref: 2018-0031
All 1 response received
· Deadline: 3 Aug 2018
Coroner's Concerns (AI summary)
The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and a referral to a drug and alcohol service was not followed up by the hospital.
View full coroner's concerns
_ At the inquest evidence was given by who was at that time a consultant psychiatrist at Oxleas. On 14 March 2017 Mr Vukovic had been admitted to Oxleas under s2 MHA, He was not previously known to services and this was his first psychiatric admission. He was expressing paranoid psychotic symptoms He was discharged from section on 27 March 2017 and he_returnedhome_Prior to discharge he had been assessed by the Early
Intervention Service (EIS) but was considered to be ineligible for their service_ He was then referred to the Home Treatment Team (HTT) and to Lifeline (a drug and alcohol service): The presumptive diagnosis was that the psychosis was druglalcohol related, but the evidence was that this could only be confirmed after he had remained abstinent for a of 4-6 weeks; there was stili a possibility that this was a primary psychosis_ My specific concerns are as follows: levidence was that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team.
(2) The referral to Lifeline required Mr Vukovic to make the initial contact himself. He did not do so, and Oxleas did not check whether or not he had done so. The evidence was that if he had been under the care of the HTT he would have been encouraged to engage with Lifeline_ (3) The result was that Mr Vukovic was discharged from hospital without follow up.
Intervention Service (EIS) but was considered to be ineligible for their service_ He was then referred to the Home Treatment Team (HTT) and to Lifeline (a drug and alcohol service): The presumptive diagnosis was that the psychosis was druglalcohol related, but the evidence was that this could only be confirmed after he had remained abstinent for a of 4-6 weeks; there was stili a possibility that this was a primary psychosis_ My specific concerns are as follows: levidence was that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team.
(2) The referral to Lifeline required Mr Vukovic to make the initial contact himself. He did not do so, and Oxleas did not check whether or not he had done so. The evidence was that if he had been under the care of the HTT he would have been encouraged to engage with Lifeline_ (3) The result was that Mr Vukovic was discharged from hospital without follow up.
Responses
Noted
Oxleas NHS Foundation Trust states that Mr. Vukovic was not referred to the Home Treatment Team and explains why. They note that Lifeline would not have been able to provide support and state Mr. Vukovic was discharged to a family who had been involved in his care. (AI summary)
Oxleas NHS Foundation Trust states that Mr. Vukovic was not referred to the Home Treatment Team and explains why. They note that Lifeline would not have been able to provide support and state Mr. Vukovic was discharged to a family who had been involved in his care. (AI summary)
View full response
Dear Mr Barlow RE: Preventing Future Death report touching the death of Michael Vukovic case ref: 01925/2017 Thank you for your letter of 02 February 2018, received on 06 February 2018 and requiring a response by 30 March 2018. The Deputy Coroner Barlow identified concerns and requested details of actions that were being taken to address these_ Each matter of concern is addressed in turn: '1) Dr Apio's evidence was that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team Our local investigation carried out using route cause analysis methodology found that in fact Mr Vukovic had not been referred to the Home Treatment Team This seems reasonable as there had been no self-harm as part of his admission, he engaged well on the ward and Mr Vukovic and his family were involved in the care plans: He was discharged to the family home: (2) The reterral to Lifeline required Mr Vukovic to make the initial contact himself. He did not do so, and Oxleas did not check whether or not he had done sO_ The evidence was that if he had been under the care of the Home Treatment Team he would have been encouraged to engage with Lifeline. RECEIvED 2018
Although Mr Vukovic was on a Greenwich ward, he had a Bexley GP. Lifeline would therefore have not been able to provide support The support worker form Lifeline who visited Mr Vukovic on the ward provided him with the details of Pier Road. Pier Road is a service external to Oxleas that supports Bexley residents with and alcohol issues. The crux is with this and other similar services on the individual to engage: (3) Mr Vukovic was discharged from hospital without follow up. Mr Vukovic had diagnosis of mental and behavioural disorder due to use of alcohol: He was not prescribed any ongoing antipsychotic medication, the early intervention in psychosis assessment concludes that his psychotic symptoms and hallucinations occurred as a result of alcohol withdrawal and this is supported by his quick recovery following detox: He was discharged to a family who had been involved in his care and treatment and who knew how to access crisis support if required. hope that my response has addressed your concerns.
Although Mr Vukovic was on a Greenwich ward, he had a Bexley GP. Lifeline would therefore have not been able to provide support The support worker form Lifeline who visited Mr Vukovic on the ward provided him with the details of Pier Road. Pier Road is a service external to Oxleas that supports Bexley residents with and alcohol issues. The crux is with this and other similar services on the individual to engage: (3) Mr Vukovic was discharged from hospital without follow up. Mr Vukovic had diagnosis of mental and behavioural disorder due to use of alcohol: He was not prescribed any ongoing antipsychotic medication, the early intervention in psychosis assessment concludes that his psychotic symptoms and hallucinations occurred as a result of alcohol withdrawal and this is supported by his quick recovery following detox: He was discharged to a family who had been involved in his care and treatment and who knew how to access crisis support if required. hope that my response has addressed your concerns.
Sent To
- Oxleas NHS Trust
Response Status
Linked responses
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56-Day Deadline
3 Aug 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
Report Sections
Investigation and Inquest
On 24 July 2017 commenced an investigation into the death of Michael Vukovic, age The investigation concluded at the end of the inquest on 22 January 2018. The conclusion of the inquest was: Medical cause of death: 1a Hypoxic brain injury due to prolonged cardiac arrest 1b Prolonged cardiac arrest 1c Traumatic L1 vertebral fracture and lumbosacral soft tissue haemorrhage The narrative conclusion was as follows: Mr Vucovic jumped from a building while suffering psychosis
Circumstances of the Death
On 8 July 2017 Michael Vukovic, who was suffering psychosis, jumped from a 2nd or 3rd floor balcony and suffered a fracture to the L1 vertebra He was admitted to Queen Elizabeth Hospital where he suffered a cardiac arrest which caused hypoxic brain damage. He was transferred to Kings College Hospital where he died on 11 July 2017.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you or your organisation has the power to take such action:
Inquest Conclusion
Mr Vucovic jumped from a building while suffering psychosis
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.