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Alan Hunter inquest finds care failings

We have recently supported the family of Norwich grandfather, Alan Hunter, at the inquest into his death which concluded at Norfolk Coroner’s Court on the 9th March.

The 72-year-old, who had been suffering from severe depression, had been under the care and treatment of the mental health services of Norfolk and Suffolk NHS Foundation Trust (NSFT) since 2019. Tragically on 17th October 2020, Alan was found dead at his home having taken his own life.

The four-day inquest heard about Alan’s life and the events leading up to his death, including expert evidence from consultant psychiatrists. In concluding, His Majesty’s Area Coroner, Yvonne Blake, found failings by the NSFT regarding the assessment of Alan’s state of mind and the lack of care plan put in place for him.

Jenny Fraser, our solicitor who represented Alan’s daughters, Claire Parker and Becky Hunter, said: “It is sad to see another mental health death in the community. It is crucial that lessons are learnt by all to prevent any future deaths from occurring. It is vitally important that all service users of mental health services are receiving the medical treatment they require and need, as well as appropriate monitoring.”

Claire Parker and Becky Hunter, commented: ‘We always knew that our dad’s death could have been prevented. He was failed by a broken system whereby he received a very substandard level of care, this is despite his high risk of self-harm and ongoing depression.

“Our dad was given no hope by any member of the community mental health team. We fear for current and future service users of mental health services in the region. Trying to live through a nightmare of supporting our dad is unexplainable. Yet despite how incredibly tough living with this was, it doesn’t compare to the emotions we now feel having lost dad in these circumstances. At times, this grief is more exhausting, overwhelming and relentless. There is no easy way to navigate it, as it is there every day, which is hard with a young family to take care of too. We are broken by our loss and worry daily that we will never be as happy as we once were.

“We relive the day dad died frequently and torment ourselves with a million different ‘what ifs’ and ‘if onlys’. We are haunted by the memories and thoughts of how he died and feel utterly devastated that we and our young families, will never get to see, hug and laugh with dad again. We feel physical pain when this realisation catches us, often in moments when we desperately want to feel some joy again. No amount of words here can get close to describing how much of an impact losing dad this way has had on our lives. Having spent over a year trying to help him recover, and putting the rest of our lives on hold to do so, we live with a sense that we failed dad. He shouldn’t have died and we shouldn’t have to live our lives feeling this way.

“We would like to thank Oliver and Jenny for all their assistance, as well Dr Hameed and Dr Mynors Wallis, for providing their evidence to the court regarding our dad’s care. We do now have more insight into what happened and sadly the care dad should have had, but this only adds to our feelings of sadness and grief, when we just want to be able to remember our dad and all the good times.

The inquest

Before HM Area Coroner, Yvonne Blake

Norfolk Coroner’s Court, County Hall, Martineau Lane, Norwich, NR1 2DH

6th March to 9th March 2023

The family was represented by Jenny Fraser of Fosters Solicitors and Dr Oliver Lewis from Doughty Street Chambers.

Alan Hunter, a 72-year-old man who loved to travel and loved nothing more than his family and friends, had been suffering from severe depression and impulsive thoughts of self-harm, with feelings of ‘doom’ and ‘living in hell’. He was found hanging in his property on 17th October 2020.

An inquest touching upon his death concluded on 9th March 2023 and heard the expert evidence of Dr L Mynors Wallis, Consultant Psychiatrist and Dr Hugh Series, Consultant Old Age Psychiatrist.

Alan was under the care and treatment of the mental health services of Norfolk and Suffolk NHS Foundation Trust (NSFT) from September 2019. He self-harmed in early 2020, which included an overdose of medication and making severe lacerations to his arms and legs which resulted in surgery. Alan was admitted to hospital on a voluntary basis, where he improved and so was discharged into the community on 20th April 2020.

In the community, Alan was allocated a care co-ordinator, was placed on FACT (Flexible Assertive Community Treatment-stepped up level of care) and received telephone contact from various support workers.

Between 30th September and 2nd October 2020, Alan had relapsed in his depression and carried out a significant and dangerous act of self-harm, by cutting the cord on his iron, taping the wires to the back of his damp hand and plugging it into the socket with the hope to electrocute himself. A meeting with Alan, his family and his care co-ordinator took place on 6th October. During this meeting, no solutions to support or treat Alan were provided by his care co-ordinator, except for the suggestion of trying Sudoku to help with his anxiety.

Both experts agreed that this was a significant event and Alan was at risk of self-harm. Dr Mynors Wallis identified that in the hundreds of people who have attempted to harm themselves, he has never seen anyone cut off the cord of an iron. Alan had chosen a method of self-harm of high lethality and so this was significant and dangerous behaviour which should have triggered a mental health act assessment, and in turn would have resulted in a hospital admission to keep him safe. The result of the meeting was that Alan would receive support via telephone calls. These calls took place on 9th and 16th October. On the 9th October, a clinical support worker rang Alan and he expressed that he feels like being in living hell and has thoughts of self-harming running through his mind.

On 12th October, Alan went missing for seven hours to clear his head and upon his return disclosed that he was going to starve himself to death. No further assessment or review was carried out by the community mental health team.

A second support call took place, with the same clinical support worker, on the 16th October. During the call, Alan was still suffering from thoughts of harming himself. During neither of these support calls did the clinical support worker explore with Alan his thoughts of self-harm or living in hell, as she saw the purpose of her calls were to maintain contact and not an assessment. These calls were not escalated to Alan’s care co-ordinator, or any member of the team. Unfortunately, the clinical support worker confirmed that they were not overly trained in making such calls. On the same day Alan purchased a rope, which he later used to take his own life the following day.

A serious incident report was carried out by NSFT, which found that the root cause to Alan’s death was that there was no pathway for older people, aged 70-75, and namely that Alan had no consultant psychiatrist monitoring his care. Alan’s care co-ordinator confirmed that she didn’t know who Alan’s psychiatrist was and the team didn’t have a named psychiatrist to deal with patients aged 70-74. Dr Mynors Wallis confirmed that providing treatment is not necessarily about the specific pathway, it is about providing treatment on each patient’s needs. Dr Hameed, a consultant psychiatrist in older people, carried out an assessment on Alan on 11th August 2020, and confirmed that Alan really needed a psychiatrist and didn’t need an old age psychiatrist.

His Majesty’s Area Coroner concluded the following:

Mr Hunter took his life on 17th October 2020, however there is clear evidence that his mental health had deteriorated since his discharge on 20th April 2020, distorting his thought process and decision-making processes.

His Majesty’s Area Coroner also found the following failings:

  • the NSFT notes were of poor quality and do not reflect details of Mr Hunter
  • no detailed assessment on Mr Hunter’s mental health state or therapeutic plan was carried out on 6th October 2020
  • there was no active care plan in place, the plan in place had not been updated since April 2020, did not detail a proper plan listing methods whereby Mr Hunter could calm and reassure himself, nor was there any numbers to call if in crisis
  • there was no named consultant psychiatrist in place, or at least staff were not aware of who to contact if they had concerns
  • a Mental Health Act Assessment should have been asked for, or a senior consultant psychiatrist, should have been requested to review Mr Hunter
  • presentation of doom and impulsive thoughts of self-harm should have caused heightened concerns
  • if Mr Hunter had been admitted on or around 6th October, on balance of probabilities his death would have been prevented.

Dr Mynors Wallis identified that when managing patients with depression, an aspect of their care plan is to instil hope in patient recovery and battle their sense that they will never get better. A care plan is fundamental in practice. It is a living document which the patient has and holds. It sets out the treatment plan and how each patient is going to be managed, as well as setting out methods on how each patient will recover – as well as reasons to live and a safety plan and thus gives a patient hope. Alan never had an up-to-date care plan, safety plan or contingency plan. Dr Mynors Wallis confirmed that there was a failure to undertake an adequate risk assessment and put in place a plan to mitigate that risk, following Alan’s attempt to electrocute himself. Sadly, this failure did contribute to his death.

Fosters Solicitors has considerable experience in representing families at inquests across the country. If you have lost a loved one and would like to discuss the possibility of representation and how our team can help support your family – please contact us for a no-obligation chat on 01603 620508, or by email. More information is also available on our Inquests page.

This article was produced on the 16th March 2023 by our Medical Negligence & Inquests team for information purposes only and should not be construed or relied upon as specific legal advice.