27 October 2022

Before HM Senior Coroner John Ellery
Shropshire Coroner’s Court
Heard 18 – 20 October 2022
Concluded 27 October 2022

A critical inquest has concluded into the death of a young man, who died following an overdose after he was able to access drugs whilst a mental health inpatient at The Redwoods Centre in Shrewsbury, run by Midlands Partnership NHS Foundation Trust (MPFT).

The coroner found that Richard Flight’s death may have been contributed to by “a dysfunctional information chain and system for identifying suspected overdose cases”, and highlighted missed opportunities in giving him medical attention, which may have prevented his death.

Richard was 23 years old when he died and was from Shrewsbury. His family describe him as a bright and caring young man who had a great sense of humour and was deeply loyal. Richard was a hard working trainee chef who had worked in a range of local pubs and restaurants. At the time of his death he was working in a speciality coffee roastery, which was a job he loved.

Richard had a history of mental ill health and had struggled with alcohol and drug use since his teens. He had benefitted from rehabilitation and recovery programmes in recent years, and particularly benefitted from the support of members of Narcotics Anonymous. However, he found it hard to access mental health support in the community, often falling through the gaps between mental health services and drug and alcohol services.

In the months prior to his death Richard made huge strides to remain abstinent from drugs and alcohol for two significant periods of time. Sadly however, his mental health declined and he needed support.

On 18 September 2021, Richard called the police whilst he was at immediate risk of suicide. He had relapsed and was under the influence of alcohol and drugs. The police took him to a place of safety using their powers under the Mental Health Act. The next day, Richard was transferred as an informal patient to Laurel Ward at The Redwoods Centre, a specialist mental health inpatient facility.

Richard had initially expressed hope that he would be able to access the support he needed there. However, on 24 and 25 September, Richard was allowed leave from the centre and go into town due to his status as an informal patient. The next day on the ward he was drowsy and unstable on his feet. A urine sample showed that he tested positive for THC (cannabis).

The nurse on duty that night again recorded that Richard appeared to be under the influence of an illicit substance. The same observation was made the next morning 27 September, and this time a further drug test recorded a positive result for cocaine and amphetamines. Despite this, Richard was allowed to leave the ward again between 4.30pm and 8.30pm.

Shortly before midnight that evening, Richard made alarming and panicked remarks to staff and said he felt like his ‘brain wants to come off’. The nurse in charge took Richard’s vital signs and called the duty doctor, who declined to attend. The nurse then administered detox medication and the sedative Zopiclone, but did not repeat clinical observations thereafter.  

By 4am on 28 September, Richard was unable to stand or reach his bedroom. He was left in a dark lounge by staff. Despite his concerning presentation and the fact that he had been administered medication that required regular clinical observations, checks were not carried out.

At 9am, Richard was found unresponsive. He was transferred to the general hospital in Shrewsbury where he received critical care over the following days. His physical condition declined and he died on 6 October 2021.

The coroner found that Richard’s death was caused by a brain injury relating to a mixed drug overdose and concluded that:

• “There was reason to suspect Richard was taking illicit drugs either when on town leave or on the ward.”
• “Opportunities were lost for Richard to receive medical attention” on two occasions at The Redwoods Centre, in the hours before he was taken to hospital.
• “On the second occasion it is likely Richard would then have been admitted to Royal Shrewsbury Hospital to receive treatment from which he may have recovered.”
• “A dysfunctional information chain and system for identifying suspected overdose cases may have contributed to his death.”

The family of Richard Flight said: “We have waited over a year for the inquest. This has been hard to bear and has impacted heavily on our ability to grieve. From the beginning we feel we were up against an organisation that did not appear to care about our family.

We feel it is incredible that in the end the coroner had to use his powers to make sure key witnesses were actually present. And, having finally heard all the evidence and answers to our questions we feel justified in our criticism of the treatment that our son received at the Redwoods Centre. What we heard was a catalogue of errors which led to the death of our son.

During the inquest we heard key facts being disputed by different members of staff. Clear systematic failures in the processes were exposed that led to critical gaps in communication between senior and junior staff and between day and night shifts. We feel that the Trust let the family and our son down in these matters and have added to our pain and suffering. As a publicly funded body, we would not have expected this.

We will not leave this here. We will be contacting the quality regulator for the Trust to request they investigate the serious matters that came to light at the inquest and see if they are satisfied with the improvements the Trust say they have made. We will do this for the sake of other families who we hope will never have to experience anything like this in the future. But for now, we will try to start grieving properly for the loss of our much-loved son, brother, grandson and friend.”

Deborah Coles, Director of INQUEST, said: “The death of this young man in these circumstances is yet more evidence of systemic failures in mental health wards nationally.

That inpatients in need of care for alcohol and drug dependency, shortly after suicide attempts, are able to walk out of secure units and access drugs is shocking. Yet sadly Richard’s death is not the first in such circumstances.

INQUEST is calling for a statutory public inquiry into deaths in mental health settings nationally, to inform change and end preventable deaths like Richard’s.”

Ruth Bundey of Harrison Bundey Solicitors, who represented the family, said: “Discovering the identity of relevant witnesses responsible for Rich’s welfare has been like pulling teeth: an inexcusably painful process for his family to experience.

Had they known of the incompetence and lack of information sharing at the Redwoods, they would have done all in their power to ensure that their son, a voluntary patient, left immediately.

We are grateful to the coroner for his careful analysis of the contradictions which emerged in evidence, and his recognition of the missed opportunities for rendering care which may well have saved Rich’s life.”

ENDS

NOTES TO EDITORS

For further information please contact Lucy McKay on [email protected]

A photo of Richard is available for media use here.

The family is represented by INQUEST Lawyers Group member Ruth Bundey of Harrison Bundey Solicitors. The caseworker is Yohanah Rodney.

Other interested persons represented at the inquest are Midlands Partnership NHS Foundation Trust (MPFT).

In May 2022, the inquest into the death from drug overdose of Alex Nova at a Priory run mental health unit in Hertfordshire concluded with critical findings. See the media release.