29 March 2018

Before HM Senior Coroner Alison Mutch OBE
Stockport Coroner’s Court, 1 Mount Tabor Street, Stockport SK1 3AG

19 - 22 March 2018

An inquest has concluded into the death of Adrian Jennings, 32, who died in Tameside General Hospital, two weeks after being discharged from an inpatient mental health unit. The Coroner concluded that Adrian’s death was drug-related, contributed to by a failure to put in place and communicate an effective support plan following discharge from hospital. The Coroner also advised the Court that she would be preparing a Prevention of Future Deaths report.

Adrian was referred to mental health services on multiple occasions. In October 2016, Adrian’s family became concerned after his health appeared to deteriorate, with Adrian appearing to be responding to visual and auditory hallucinations.  As a result on 31 October, Adrian’s mother took him to A&E, where he was admitted to Taylor Ward at Tameside General Hospital, an inpatient mental health ward.

In evidence, the Coroner heard how Adrian was encouraged to take home leave from a very early point in his admission. However, Adrian was anxious about leaving the ward. His family were extremely concerned about him leaving the ward and there being a lack of an adequate support plan post discharge.

Following his discharge on 28 November, Adrian was supported by Pennine Cares Home Treatment Team (HTT). The Coroner heard however, that there was uncertainty in how Adrian’s care was going to proceed following this, with there potentially being a minimum two weeks gap where Adrian would not be supported by any mental health services, despite his recent inpatient discharge. Adrian was told his support by the HTT was going to end on 12 December and was not given any advice about further support.

In the two days prior to Adrian’s death, Adrian’s family became concerned about Adrian. Both Adrian’s mother and GP attempted to contact the mental health services, including Pennine Care Healthy Minds, to whom two referrals had been made. However, there was no clear communication about who was to continue Adrian’s care and ensure his safety. It was accepted in evidence that there were clear commissioning gaps in provision of care to people, like Adrian, who are neither diagnosed with a psychiatric disorder and are also not on the low depressive spectrum.

Around 2.30am on 10 December, Greater Manchester Police found Adrian on the street chewing tablets. He informed them he had taken a variety of drugs and the police escorted Adrian to A&E. The police stayed with Adrian while he was booked into A&E and Adrian informed the receptionist that he had been a recent inpatient. Despite this, this information and that Adrian had been brought in by GMP was not communicated further. The police left A&E after Adrian was directed to take a seat and before triage, Adrian left the ward. The hospital’s missing person’s procedure has since changed following a challenge from Adrian’s family. The Inquest heard that Adrian would now have been classed as a high risk person and the police would have been alerted upon his absconding.

Adrian’s movements following this are uncertain however, he was found unresponsive at a house and later pronounced dead at Tameside General Hospital at 21.27 on 10 December 2016. 

The coroner found the following:

• Communication between the Pennine Care Teams involved was poor and hampered by the use of different I.T systems.
• There was a failure to effectively communicate with Adrian Jennings and his family.
• It is probable that the lack of effective support and poor communication in relation to the support plan contributed to his death.
• On the 9th December 2016, in the absence of a clear support plan and when attempts to obtain clear information had been unsuccessful, Adrian Jennings took a cocktail of drugs and alcohol.
• At booking in [in A&E] there was a failure to record key information by the staff. This meant there was a missed opportunity to record how high risk he presented.
• His absence was not reported to Greater Manchester Police because the policy had a gap which meant that high risk absconding patients between booking in and triage were not reportable. It is possible that this also contributed to his death.

The family of Adrian Jennings said: “Our family has been left distraught following the unnecessary and tragic death of our son. Adrian was a kind, considerate caring young man who was clearly struggling to manage his own mental health and wellbeing. Over a number of months Adrian tried in vain to reach out to professionals for help and support. Unfortunately, little regard was given to Adrian’s vulnerability and he found the minimum service that was made available was disjointed and insufficient.     

Following Adrian’s death the burning questions we asked ourselves were, did we do everything we could to gain support for Adrian? Did we call enough people or shout loud enough to be heard? Was there more we could have done? Given the evidence that was heard during Adrian’s inquest it became clear that as a family we had not failed our son, although this may not be said for some of the professionals involved in his care. 

We are saddened to say it appears that services available for people who are experiencing mental illness are wholly lacking and pathways to care are unclear and littered with inadequacies. As a consequence people who are least able to speak out are faced with scant ineffective care and support.

We will miss Adrian for the rest of our lives but hope that changes will be made in the near future to avoid further deaths following the recommendations made by the Coroner.

We would also like to thank INQUEST, and our legal team for all the support offered to us during this challenging time, without which our journey through the legal system would have been extremely lonely”.

 

Gemma Vine of Minton Morrill Solicitors: “This is a deeply tragic case of a vulnerable young man who was failed by multiple state agencies. His death highlights the need for a clear care package for those being discharged from an inpatient mental health unit into the community and furthermore, demonstrates clear commissioning gaps for mental health care, where vulnerable people are falling through the cracks.”

ENDS

NOTES TO EDITORS

For more information contact Lucy McKay on 020 7263 1111 or [email protected]

The family is represented by INQUEST Lawyers Group member Gemma Vine of Minton Morrill Solicitors and Camille Warren of Garden Court North Chambers.

The interested persons represented at the inquest were Greater Manchester Police, Pennine Care NHS Foundation Trust, and Tameside and Glossop Integrated Care NHS Foundation Trust.