Before HM Assistant Coroner Nick Brown

Exeter and Greater Devon Coroner’s Court

10 – 13 May 2021

Timothy Hunt, 50, died under the care of Somerset Partnership NHS Foundation Trust. He took an overdose with alcohol whilst on extended home leave from admission as a voluntary mental health patient at the Rydon mental health ward in Wellsprings Hospital, Taunton. He was found collapsed on the floor and taken to general hospital where he died a few days later on 26 October 2018. An inquest into Timothy’s death opened in May of this year, with evidence over three days examining the care he received.

The coroner found that Timothy’s death was caused by suicide contributed to by neglect and that:

• Timothy most likely took an overdose with alcohol on the evening of Sunday 21 October 2018 and collapsed on the floor in a very cold house until he was found on Tuesday 23 October at around 1pm This period without adequate hydration caused irreversible damage to his kidneys.
• There was some delay in an ambulance attending on Tuesday but this was of no causal significance.
• The staff from Rydon Ward did not wait with Timothy until the ambulance arrived, leaving him alone for more than one and a half hours before ambulance staff reached him at about 4.10pm.
• Timothy was taken to Musgrove Park Hospital for treatment, which was appropriate but unsuccessful.

Timothy had a long history of mental ill-health and had a diagnosis of bipolar disorder. His family describe him as a kind and loving man. Despite his great difficulties with his mental health, the people that knew him would remember him as a chatty, happy-go-lucky person with a great sense of humour. Although unable to work due to the severity of his illness, he enjoyed DIY projects in his garden and home.

In the months before his death, Timothy was in and out of mental health hospital following self-harm incidents and overdose attempts, both as a detained and voluntary patient, primarily at Rydon Ward run by Somerset Partnership NHS Foundation Trust. His final admission was on 15 July 2018 as a voluntary inpatient.

On 5 October 2018, Timothy was encouraged to take a period of overnight leave. Upon his return, he reported feeling anxious and in a meeting with his care coordinator a few days later to discuss future plans, Timothy was found to be at high risk of suicide. On 10 October, Timothy was assessed on the ward and, as part of the discharge process, a further period of home leave was arranged for 11-17 October. No plans or arrangements were made to monitor, support or keep Timothy safe before he went on this period of extended home leave.

During this time, Timothy’s mental health was deteriorating rapidly; he stayed in bed and did not eat or drink properly. On 16 October, a multi-agency meeting was held between mental health services involved in his care and local police to discuss preparations for his discharge. His risk at this stage remained high. On 17 October, Timothy did not return to the ward as scheduled and said he could not come in as he had injured his foot.

On 19 October, the Home Treatment Team visited Timothy, finding him in a low mood and refusing to return to the ward. He was clearly unable to cope at home and needed to return to hospital. However, he was left on his own and the only follow up arrangements were to call Timothy the following day.

On Saturday 20 October, after a member of the Home Treatment team spoke to Timothy, he was discharged back into the care of the staff of Rydon Ward. No members of the Rydon Ward took any action over the weekend and they did not visit or arrange a visit Timothy on Saturday, Sunday or Monday.

After Timothy failed to answer telephone calls on Monday and Tuesday morning, two members of staff from Rydon Ward went to his house to check on him, arriving at around 1.15pm. Timothy was found conscious but lying down on the kitchen floor and appeared confused with slurred speech. The nurse rang 999 to request an emergency ambulance shortly afterwards.

Timothy arrived at hospital at 6.13pm. He was seen by the Psychiatric Liaison Team who advised Timothy would be treated in his best interests under the Mental Capacity Act. Timothy’s presentation was assessed as one of acute drug toxicity, resulting in life-threatening kidney issues.

On 25 October, Timothy was able to confirm he had overdosed. He was transferred to Devon and Exeter Hospital for treatment and started dialysis. On 26 October, Timothy’s condition deteriorated and he became unresponsive. His death was pronounced at 10.14pm.

On the coroner’s request, the Somerset Foundation Trust provided a report on the changes that had been made to mitigate the risk of repeat failings, which the family were broadly content with, including:

• The process for planning for discharge from hospital should commence at the first multi-disciplinary team review following the patient’s admission to hospital, which would enable the team, patient, family/carers and significant others the opportunity to discuss the patient’s presentation, risk to self and others and ongoing care needs.
• Extended home leave should not be considered a separate therapeutic intervention but part of the process for planning for discharge. The same level of consideration and planning for discharge needs to take place for patients commencing leave from the ward, to ensure their care needs can be met.
• The Care Coordinator and/or representatives from the community team would be informed of planned overnight leave and there would be information on a care plan or safety plan in relation to deterioration and safety arrangements. There must also be appropriate documented risk management plans in place to support the patient in the event that their health deteriorates during leave.
• The Care Coordinator is responsible for monitoring and managing the care plan, which will include close monitoring of the patient and early identification of and action on community issues.
• All patients admitted to mental health wards within the Trust will have at minimum a weekly MDT review, which will include the formulation of a care plan and identify any barriers to discharge.

Janine Toon, Timothy’s daughter, said: “I am so thankful to the coroner for the sensitive but direct way he handled my father’s inquest that helped me and others to understand the full extent of what happened in the period leading up to his death. I feel a weight has been lifted from my shoulders as I am no longer the only one who knows my father was failed by the mental health services. I feel that uncovering the truth about what happened has given me some peace.

Whilst I will always feel great sadness at the events that unfolded and the fact my dad is no longer here, my mind has now been put at ease that the Trust now has made changes to ensure that this terrible tragedy will never happen again. I am very grateful and feel happy that the conclusion delivered should bring about positive change for others in the future.”

Elliot White, solicitor for the family, said: “The coroner’s finding of suicide with neglect confirms what Timothy’s family had always known, that he was failed by the Trust and his death was preventable. If a care plan had been developed which set out the measures and arrangements which needed to be in place to monitor Timothy and support him and to keep him safe, with identifiable warning signs; or if Timothy had been taken back to the ward on Friday when he was so clearly in need; or at the very least, visited at home on either Saturday, Sunday or Monday; if any one of these gross failures had been averted, he may still be alive today.”

Nancy Kelehar, INQUEST caseworker, said: “The number of failings and inadequate actions by Somerset Foundation Trust in the days before Timothy's death are appalling. The risks of extended home leave were not sufficiently considered and Timothy was left alone and uncared for while he was extremely vulnerable. We commend the coroner's critical findings and their follow up action in obtaining information about the essential changes that have been implemented by the Trust.

Timothy's daughter, Janine, has demonstrated incredible strength and resolve throughout the difficult inquest process. By undertaking a thorough investigation, the coroner has provided the forum for the family to obtain crucial answers and accountability for the preventable death of their loved one.”

ENDS

NOTES TO EDITORS
For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected].

Timothy’s family are represented by INQUEST Lawyers Group members, Elliot White of Deighton Pierce Glynn and Nick Stanage of Doughty Street Chambers. The family are supported by INQUEST caseworker Nancy Kelehar.

Other Interested Persons represented are Devon Partnership NHS Trust, Somerset Partnership NHS Trust and Royal Devon and Exeter NHS Trust and South Western Ambulance Service.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.