Failures found by Michael Holland Inquest

A recent inquest into the death of Sussex-man, Michael Holland, has concluded by highlighting failures by his local NHS Trust to communicate with his family when he could not be contacted following discharge from a psychiatric hospital.

Michael was 45 years old when he died from an overdose on the 2^nd December 2021, hours after Sussex police and paramedics found him in the act of self-harming during a welfare check. He died only three days after being discharged from Langley Green Hospital, Crawley, after being held as an inpatient under section. A Coroner has concluded that his medical cause of death was morphine toxicity and bronchopneumonia.

After a five-day inquest, where Michael’s family were represented by Jenny Fraser and Jazz Balmer of Fosters Solicitors, and Jonathan Metzer of 1 Crown Office Row, the following failures were highlighted:

• Shortcomings in the system allowed Michael’s repeat prescribed medication to be ordered from his GP surgery during the time in which he remained an inpatient.
• Face to face contact expected by Michael’s lead practitioner during the 72 hour follow-up period was sub-optimally replaced with telephone contact by ward staff.
• There was a failure to communicate difficulties in completing a welfare check within the critical 72 hour follow-up period following discharge to Michael’s mother. This was contrary to care policies.
• Following the text message sent by Michael to another patient on the ward indicating that he had taken an overdose, less than an hour after the paramedics’ departed, there was a missed opportunity to alert emergency services to a possible overdose and request urgent re-attendance by the paramedics.

Speaking at the conclusion of the inquest, Michael’s mother, said: “The court has recognised that there was a failure to communicate the discharge plan and a failure to follow-up with me when Michael could not be contacted during the 72 hour window following his discharge. It is vital that mental health teams make full use of the unique insight that a family can have in managing a person’s risk.

 “During Michael’s stay at Langley Green, I found myself continually having to contact the hospital in order to be kept updated. Approaching discharge, I repeatedly told staff, “He won’t answer the phone, contact me first”. This request was not listened to. I am convinced that if I had been contacted after Michael’s discharge, we would not be here today.”

Jenny Fraser and Jazz Balmer of Fosters Solicitors, added: “It has been a privilege to represent Michael’s Family in this tragic case. It has been a long process to reach the inquest’s conclusion, and tireless efforts have been made throughout to ensure that the full facts are brought to light. Failures have been recognised and it is sincerely hoped that improvement will now be made to prevent similar failings from reoccurring in future circumstances.”

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.

For more details surrounding the inquest into the death of Michael Holland, please click here for the full report by charity, INQUEST, who have supported Michael’s family.