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Family calls for better coordination between mental health, social care and drug and alcohol services in Kent

A failure to communicate between services and provide appropriate care were factors in the death of 31-year-old Kent man Hadley Savory, an inquest has concluded.

Posted on 20 August 2021

At the end of the inquest on 11 August, Assistant Coroner Ian Brownhill, sitting in Maidstone, Kent, made a Prevention of Future Deaths report addressed to Kent County Council (KCC) which lists a number of issued raised by the inquest that need to be reviewed, including: how internal disagreements within KCC as to allocation of cases are recorded; information sharing between services in relation to people with fluctuating capacity; ensuring service users’ needs are met under the Care Act when transferring between services; and the interrelation with Kent and Medway NHS and Social Care Partnership Trust (KMPT) of safeguarding services, and operation of policies and procedures for people who self-neglect.
The Coroner also directed a prevention of future deaths report to all of the applicable services asking about multi-agency approach to hospital discharge planning in respect of complex cases where individuals present with concurrent mental health, physical health, substance abuse, and social care needs. As well as KCC and KMPT, the Forward Trust, a charity that provides addiction services for KMPT were also involved in Hadley’s care.
Hadley was found dead on 13 December 2019 at his home in Margate, Kent. In the months leading to his death, a referral to the community mental health team went missing and no services were put in place to meet his significant social care needs. He was self-neglecting and at risk of accidental overdose of Methadone. The Coroner descripbed the support provided to Hadley as "sub-optimal".
Following discharge from hospital on 25 September 2019, Hadley was not contacted to arrange any follow-up support from KPMT's Community Mental Health Team. Two email referrals to the service were simply not actioned.
The Coroner delivered a short-form conclusion of drug-related death, with an additional narrative:
“Hadley was discharged from Queen Elizabeth the Queen Mother Hospital on 25 September 2019. The plan for this care and support in the community was unclear. Attempts were made to engage with him however communication between the bodies who were providing services to him was sub-optimal and Hadley’s presentation deteriorated. His presentation was identified but no coordinated multi-disciplinary response was arranged prior to his death.”
Hadley had been in contact with mental health services since 2011 when he had been diagnosed with schizophrenia and depression and received treatment from the community mental health team. He was prescribed methadone at this time for codeine dependency.
Hadley’s family told the inquest that his mental health had deteriorated during 2019. On 2 September 2019 Hadley’s mother, Yvonne Mortlock, requested a Mental Health Act 1983 assessment for Hadley and the next day his father called an ambulance to attend because of his deteriorating mental health. He was hospitalised at Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate the following day having blacked out and was diagnosed with multiple abscesses and amnesia.
Hadley’s family said following the inquest:
“Hadley’s death has left a huge hole in all our lives. In the months before his death we could see that he was struggling with his mental health but despite our repeated efforts to try to get professional support and care to meet his needs this was never provided. After he left hospital at the end of September he just seemed to fall between the cracks of the different organisations and services who were supposed to be involved in his care, with no one communicating or coordinating any kind of plan for supporting him. We hope that, at the very least ,the services responsible for mental health care in Kent will learn from Hadley’s death and put in place clear policies for cooperation between services and safeguards to ensure that cries for help are not missed or ignored.”
Anna Dews, solicitor from Leigh Day, added:
"There needs to be a more joined up approach to the formulation of community care and mental health planning, especially when assessing needs under the Mental Capacity Act, Care Act and Mental Health Act otherwise there is a risk that there are simply too many crossed wires. Hadley was ultimately left with no care when he needed it the most."  
Leigh Day instructed Oliver Lewis of Doughty Street Chambers to represent the family.

Emma Jones

Emma Jones

Emma runs the team working on the contaminated blood inquiry 

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