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Coroner criticises Oxford Health NHS Foundation Trust over death of carpenter Roy Morris

The death of carpenter Roy Morris could have been avoided if Oxford Health NHS Foundation Trust had put in place a clear plan for his care as a community mental health patient following his discharge from a mental health care facility, a coroner has concluded. 

Posted on 26 March 2021

Coroner Crispin Giles Butler said Roy Morris died as a result of suicide to which the following contributed more than minimally:

  • The fact that there was no detailed written care plan for Roy on discharge into care in the community and the acute day hospital team
  • The fact his care coordinator was only allocated shortly before discharge
  • Roy’s family were not provided with the means to engage fully and candidly with the inpatient team.

The coroner issued two prevention of future deaths recommendations:

  • The application of care programme approach to patients such as Roy so that they have a detailed care plan
  • The importance of the role of the care coordinator and the timely allocation of this person to inpatients shortly after admission so that they can work with the patient and family and mental health teams

The inquest was told of a failure to properly plan the discharge of Roy, aged 60, following a 28-day admission to the Whiteleaf Centre in Aylesbury, which lacked a clear and comprehensive plan for his care and safety when he returned home as a community mental health patient. A worsening in Roy’s mental health condition, which included paranoid features, was not recognised effectively by those many different staff who engaged with him following his discharge.
 
Sadly, Roy’s body was found in June 2019, five weeks after he had left his home while very unwell and his family had reported him missing.
 
Nine days before he went missing, Roy had been discharged from the Whiteleaf Centre, a mental health hospital where he had been admitted as an inpatient under Section 2 of the Mental Health Act, following an attempt to take his own life. 
 
At the Article 2 compliant inquest at Beaconsfield Coroner’s Court, Roy’s family voiced concerns around the care he had received as a mental health patient. 
 
They said Roy, a talented guitarist who had no known history of anxiety, had been referred to community mental health services in April 2019 after he had developed severe work-related anxieties. He had also been experiencing acute sleeping difficulties since January. 
 
During an assessment on 19 April at The Valley Centre in High Wycombe, Roy and his family were advised that he would need to attend the Adult Day Hospital on a voluntary basis when it reopened after the Bank Holiday weekend, on account of the severity of his condition. This service provides three hours of access to clinicians on weekday mornings. Hours later, he made an attempt to take his own life. Roy was then admitted to the Whiteleaf Centre, where he spent the following 28 days as an inpatient.
 
His family were initially relieved that he had been admitted, as they thought the Whiteleaf Centre would keep him safe and provide the treatment he needed. However, they said it soon became apparent that it was “very difficult to communicate meaningfully” with staff. 
 
They say that they were rarely offered information about Roy’s care, and neither proactively approached to provide background information on Roy, nor collaborated with on his safety and care planning. The court heard that bridging the gap between what the family knew of Roy’s worsening condition, and what the clinicians were able to glean from their interactions with him, could have been crucial in keeping him safe.
 
The inquest heard from an independent expert witness, consultant psychiatrist Dr L Mynors-Wallis, that the management of Roy’s discharge from the Whiteleaf Centre, which lacked a care plan, was the “the most significant failure”. He also criticised the medication Roy was prescribed. The court heard that there should have been a careful and thorough discharge meeting involving not only Roy and his family, but crucially, his care co-ordinator. This meeting should have resulted in a shared plan for Roy’s community treatment, provided hope for a recovery, and enabled his family to recognise signs of deterioration and act on a safety plan should this happen.   
 
Roy Morris’s daughter, Ruby Morris, said:
 
“We are devastated to hear that Roy’s death could have been prevented, but we are grateful to the court and the witnesses called for allowing us to have the concerns which we have held for almost two years validated. We hope that Oxford Health NHS Foundation Trust will take this grave opportunity to implement real, substantive actions that will prevent a tragedy like this from befalling another family. While it is clear that this Trust’s practices need to change, it is apparent to me that Oxford Health’s specific failings in the care of my father reflect the larger picture of depleted mental health services nationally, with well-documented shortages of mental health clinicians and inpatient beds contributing to service inefficiencies, long waiting lists and ultimately, avoidable deaths. Mental health has been a regular topic of national discussion in recent years, and I hope that the government will go beyond lip service to provide urgent system and budget reviews that will enable the NHS to provide this country with the psychiatric services we so desperately need. I am aware that a cash injection has been pledged to mental health services by the government this year, owing in part to increased demands caused by the Covid-19 pandemic, the impact of which on local adult services remains to be seen.”
 
Ruby highlighted reports from Jan 2020 and Feb 2021: 
 

A severe shortage in hospital beds is leaving patients without treatment

Mental health workforce report

Merry Varney said:
 
“The Inquest has fully investigated how Roy Morris, a much loved partner and father, whose photo has been displayed throughout, came by his death. This recognition in the Coroner’s conclusion of the failings that lead to Roy’s death is welcome. 
 
“Roy and his family were badly let down, and this public recognition of that by a Coroner brings some accountability. It must however lead to change – too often we meet bereaved families who have lost a loved one in circumstances where community mental health provision has been poor or inadequate, with the same issues arising related to lack of care planning and involvement of the family. It is simply not good enough.”
 
Bola Awogboro, INQUEST Caseworker supporting the family said: 
 
“Proper communication and careful planning were essential to ensuring Roy’s safe discharge and this was not afforded to him. His family were tireless in advocating for his care yet their attempts to collaborate with care providers to aid his recovery were ignored.
 
“The experiences that the inquest has identified are an example of a systemic inadequacy in mental health services, particularly for those receiving treatment in the community. Sadly, INQUEST sees far too many failings in mental health provision that lead to avoidable deaths. What is required now is better resourcing for effective and responsive care.”

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Merry Varney

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