16th December 2015

Christopher Higgins was a 36 year old man, who in the last few weeks of his life suffered from his first, but acute, mental breakdown. In those last weeks, his family tried every avenue to get Christopher the help he needed. Christopher’s mental state deteriorated significantly and in the early hours of 25 June 2013, Christopher suffered from a self-inflicted fatal injury. At the time of the injury Christopher was a detained patient at the Fermoy Unit, Kings Lynn. He was in the presence of two members of staff from the Unit, run by Norfolk and Suffolk NHS Foundation Trust, and also police officers from Norfolk and Cambridgeshire Constabularies.

The family believe that effective care from the Access and Assessment Team would have saved Christopher’s life. They remain concerned that mental health services had been significantly cut and reorganised in the months prior to Christopher’s illness. The inquest heard that there were failures to arrange an adequate and urgent assessment of Christopher’s worsening mental state over a period of six weeks, and insufficient weight was given to the family’s views. The inquest also heard that the system for providing out of hours crisis psychiatric care at the time of Christopher’s death was inadequate.

Only after the police were called to the family home on 23 June 2013, was Christopher assessed and admitted to the Fermoy Unit. The risk assessment undertaken was significantly incomplete. There were failures to identify and record the nature and level of Christopher’s risks and to formulate a clear risk management plan, which were described by an independent expert reviewing the case as ‘serious omissions’. The risk assessment documentation did not note that there had been three or four self-harm or suicide attempts in Christopher’s first 24 hours on the unit, that Christopher said he would kill himself if taken into hospital, or that his family considered him to be unpredictable and a risk of impulsive suicide act.

A doctor giving evidence at the inquest agreed that given the risks involved, Christopher’s injuries from self-harm could have been treated at the Fermoy Unit. Instead, Christopher was sent to the Queen Elizabeth Hospital on the evening of 24 June 2013, with a healthcare assistant who knew barely anything about Christopher. Christopher had to wait 3 hours for treatment. CCTV played at the inquest showed Christopher becoming more and more withdrawn and distressed in that time.

The Trust witnesses accepted that there were inadequate safeguards put in place to protect Christopher during his time at A&E. Christopher seized a pair of scissors whilst at A&E and violently stabbed himself. He was then restrained by police using CS gas, put in a martial arts restraint hold, hit several times with a baton, and then left in handcuffs and leg braces, surrounded for some time by police officers, with no mental health staff present for some 30 minutes.

Christopher was later conveyed back to the Fermoy Unit where he was placed on 2:1 observations. During that time he was allowed outside the unit for a cigarette, to an area the family consider was not safe, and dived over the handrail on a disabled access ramp, fatally injuring himself. The doctor intended that both members of staff should be within arms length of Christopher but there was a failure to ensure the staff understood this.

On conclusion of the inquest today, HM Senior Coroner for Norfolk, Jacqueline Lake, stated she was concerned that the following issues need to be addressed at the Trust as they may give rise to circumstances in which lives could be put at risk in future:

1. Staff still do not appear to know what is required of them regarding 2:1 observations; 
2. There needs to be further consideration across the Trust of how best to deal with mental health patients who require treatment at an acute hospital, and how to communicate with other acute hospitals;
3. The escort policy should be amended to ensure that mental health staff travel alongside patients being transported by other organisations (e.g. by the police); and
4. The physical environment outside the Fermoy Unit where Christopher injured himself needs to be reviewed to see whether safety can be improved. 

Christopher’s family said:

“Christopher Higgins was a loving son who had never been in trouble with the authorities. Until the onset of his illness, he had been employed for the previous nine years in a responsible job. He was a proud man who had recently gained the necessary qualifications planned to work as a personal fitness trainer.

We believe Chris’ death was entirely avoidable in an institution where he should have been safe. If we had got the help we requested over and over again from when Chris first became ill we believe that Chris would never had to enter the Fermoy Unit, but meaningful help was not forthcoming.  A lack of urgency, coupled with muddle and lack of communication between the various parts the mental health service, led to a crisis with the police intervening. Sadly cuts in an already underfunded and already over-stretched mental health service will not only lead to tragic cases such as ours.” (Please see below the family statement in full"

Deborah Coles, co-director of INQUEST said:

“Serious failures in mental health services have gone on for far too long and the same errors which lead to preventable deaths come up time and time again.  In a report leaked to the BBC last week, it was revealed that over 1000 deaths of people with mental health problems or learning disabilities were not properly investigated by the NHS. Proper learning only comes out from independent and robust investigations.  Families deserve nothing less”

Sara Lomri, solicitor for the family said:

“Christopher’s death was one of series of ten unexpected deaths of mental health patients from the West Norfolk area between April and December 2013, which is an alarming number in such a short period. The inquest into Christopher’s death heard that there were concerns regarding risk assessments in each of the ten cases, and that improved training was required. Norfolk and Suffolk NHS Foundation Trust witnesses told the jury that since Christopher’s death they have since taken some steps to improve the systems in place.  However, the evidence indicates that there are numerous issues still outstanding which may pose a risk to life in the future”

INQUEST has been working with the family of Christopher Higgins since February 2014.  The family is represented by INQUEST Lawyers Group members Sara Lomri from Bindmans LLP and barrister Adam Straw from Doughty Street Chambers.

Family Statement

"Christopher Higgins was a loving son who had never been in trouble with the authorities. Until the onset of his illness, which resulted in Chris's resignation he had been employed for the previous nine years in a responsible job. A proud man and having recently gained the necessary qualifications planned to work as a personal fitness trainer.

Chris suffered a fatal injury at the age of 36 on the 24 June 2013  while in the care of the Norfolk and Suffolk NHS Foundation Trust, less than 36 hours after voluntary admission, a death that was both tragic and avoidable. A day after entering the Fermoy Unit we understand that Chris had self harmed four times in  more and more desperate attempts to end his life, but was still allowed to stand in an unsafe place within the courtyard of the unit where he vaulted over a barrier leading to a broken skull and fatal brain damage.

Chris became steadily more unwell in the weeks prior to his admission to the Fermoy Unit and we tried every avenue available to try to get him the help he so badly needed. We tried, in vain, to avoid a crisis occuring.

If we had got the help we requested over and over again from when Chris first became ill we believe it is probable that Chris would never had to enter the Fermoy Unit, but meaningful help was not forthcoming.  A lack of urgency, coupled with muddle and lack of communication between the various parts the mental health service, led to a crisis with the police intervening and Chris being admitted as a voluntary patient. As we understand it due to budget cuts the early intervention service of the Norfolk and Suffolk Mental health service was terminated in 2013 leaving nobody able to help us.

Sadly cuts in an already underfunded and already over-stretched  service will not only lead to tragic cases such as ours, but when they do occur to an enormous waste of scarce resources in both time and money for both the family and the National Health Service as we struggle to identify the mistakes  that allowed Chris to take his life in an institution where Chris should have been safe and where all who worked there had a duty of care.

We are dismayed and very disappointed that the Coroner saw fit not to allow the Jury to comment  on  the following serious issues that were identified during the inquest

1. Signficant failings in the systems, training and practices relevant to the provision of care to Christopher by the Trust.
2. The failure to ensure early diagnosis and initiation of treatment which we believe would have meant a signficiant improvement in Christopher’s condition and prognosis
3. The prolonged delays in arranging assessment by Access and Assessment Team (AAT) and the inadequacy of the telephone assessments when they did occur . We believe Christopher should have been assessed face to face, given the seriousness of his condition. Instead he was assessed over the telephone and the assessor was not adequately supervised.
4. As a family, we tried numerous times to call the out of hours crisis number (the 0800 service) when Chris became very seriously unwell, but in each conversation the responsibility was put back on us. Despite our very best efforts, we were unable to get through to anyone who could help. The evidence we heard was that the out of hours service was inadequate.
5. Failures in carrying out observations of Christopher when he was at the Fermoy Unit and the  lack of staff engagement.
6. Grave failings in risk assessment and risk management, which was a serious omission. There was a failure to identify the nature and degree of the risks posed to Chris and the risk management plan.
7. Failures surrounding the decision to treat Christopher in A&E on the evening of 24 June 2013 and the failure to ensure that he had adequate support and protections when he was there
8. The decision to convey Christopher back from A&E in the police van to the Fermoy Unit, after a particularly serious police restraint, without anyone from the Trust to support him 
9. The decision back at the Fermoy Unit to allow Christopher outside to smoke, despite the his very high risk of self-harm and unpredictable behaviour          (which is when he suffered the fatal injury).

 Unlike both the prison and police service, the health service does not have to initiate a fully independent investigation when an unexpected death occurs, but is allowed to investigate itself. We strongly believe that it is only after fully independent investigations, that involve from the outset the families of those who have lost their lives, that there will be assurance that mistakes and shortcomings, both personal and institutional, have been identified. Only after this can  the correct remedial actions be taken and with an agreed timetable for implementation and review.

Presumably because of the fear of litigation which might arise if there had been a critical report we believe the trust did its best to hide unwanted evidence. Statements were not obtained from the AAT clinician who undertook a face to face interview with Chris on the 17th June and downgraded his case to non-urgent. Also the Trust did not provide statements from the Junior Doctor and the Charge Nurse at the Fermoy Unit who decided to send Chris with a care support worker to A&E at the Queen Elizabeth Hospital on the evening of the 23rd June  following four incidents of self harming. This decision was particularly alarming as we believe it put both our son and the public at risk for the following reasons:

• There was no risk assessment despite Chris's increasingly unpredictable behaviour
• The care worker was medically untrained
• The care worker had not met Chris before and apparently was told nothing other than Chris had self harmed.
• The care worked had no way of contacting the Fermoy centre other than the public phone
• There was no fast track possible, Chris waited 3 hours for treatment 
• A&E is an open access area with members of the public including children present
• Although on one to one observation, a policy only adopted for mental health patients at severe risk to themselves or others, Chris on several occasions was left alone
• Chris was a big man, 6ft 4” physically very fit and much stronger than the care worker who could not have restrained Christopher.
• Several times Chris was allowed to go outside the building to the smoking shelter, not far from the very busy A47, if he wanted to he could easily have absconded.   

The expert witness, who we believed greatly influenced the Coroner's judgements, was a non-executive director of the Norfolk and Suffolk Mental Health Trust at the time he wrote his reports."