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Inquest into the death of Christopher Higgins concluded today: Coroner reports requesting changes to protect the lives of mental health patients in the future

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Christopher Higgins

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 the 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 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.”

Sara Lomri of Bindmans LLP representing 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.”

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.”

The family is represented by Sara Lomri from Bindmans LLP and Barrister Adam Straw from Doughty Street Chambers.

‘Mental health services had been significantly cut and reorganised’, ‘failures to arrange an adequate and urgent assessment’, ‘insufficient weight was given to the family’s views’; ‘out of hours crisis psychiatric care at the time of Christopher’s death was inadequate’, ‘serious omissions’, ‘healthcare assistant who knew barely anything about Christopher’, ‘serious failures in mental health services’, ‘lack of urgency’, ‘numerous issues still outstanding which may pose a risk to life in the future.’

How many more times?

How many more failures?

How many more inquests?

How many more cuts?

How many more deaths?

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6 thoughts on “Inquest into the death of Christopher Higgins concluded today: Coroner reports requesting changes to protect the lives of mental health patients in the future

  1. Terry skyrme says:

    This makes you want to cry. When will NSFT take the deaths of patients seriously? On Radio 4 today there was a feature on the fact that so many people with mental health problems are going to their MP because they cant get help from their local mental health service that Mind, Rethink and the Royal College of Psychiatry have combined together to produce a booklet of guidelines for MPs on how to deal with patients who turn up at their surgeries. Far better, I think, if these MPs had been shouting from the roof-tops in protest at all the cuts that have taken place since 2012. The Campaign to Save Mental Health Services have called on Norfolk and Suffolk Foundation Trust to place this issue at the top of their agenda, to stop trying to defend the indefensible and calmly examine what needs to be done to reduce the suicide rate in Norfolk and Suffolk. The Trust now refuses to meet with our Campaign to discuss these issues. Our last scheduled meeting with the Trust was to discuss this very issue; the Trust cancelled it and still the number of deaths of patients under their care continues to rise.

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  2. meshugana says:

    I am feeling such sadness reading about so many unexpected deaths apparently due to lack of resources, communication and prompt accurate assessment and access to treatment. When is the Trust going to drop all the defensive explanations and start to prioritise? It’s a bit rich Jane Sayer writing that the Trust investigates all unexpected deaths. What about taking measures to prevent them?

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  3. allwillbewell says:

    What a tragedy. What a waste. Family left powerless in the face of bureaucratic incompetence. Follow up by NSFT shameful.
    Did MP for King’s Lynn or family vote for Lucianna Berger’s motion for parity of esteem? This would give greater funding for MH services.

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  4. CLAIRE NOON says:

    My daughter Louise also committed suicide in July 2010 aged 24 whilst in a secure unit at Northgate Hosptal in Great Yarmouth. We also contacted Bindmans LLP to try and help us found out how this terrible tragedy could have happened. We felt after the inquest, where the Trust admitted that serious failings had led to Louise’s death there would be a massive shake up within the Trust as the Coroner made lots of recommendations to them for improvements of care. Sadly this does not seem to have happened. My thoughts are with Christopher’s family for their heartbreaking loss.

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  5. m says:

    I believe the Trust’s usual statement is that ‘deaths within NSFT, are no higher than any other Trust  in the country’……….. a comment that is as callous, and meaningless, as much of its Radical Redesign had been.  Terrible avoidable tragedies. My sincere sympathies.

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  6. Backstreet Bob says:

    It is interesting to know that at the precise time these findings were being read out, all staff in NSFT were treated to another tirade about data quality..

    Based on the October 2015 “Completed Waits” (the “waiting times” of service users who have been seen and are no longer waiting) information reported to all commissioners, there were 334 breaches and 142 (43%) of these were due to data entry issues such as ‘incorrect contact purpose’ used and ‘contact not on the system’; ultimately these breaches can compromise clinical safety and will lead to financial penalties for our Trust.

    Front line clinicians are spending 15-20% of their time battling against the incomprehensible and dysfunctional Lorenzo electronic patient record system. Patient contacts are being cancelled so that staff can chase targets updating records on closed cases so that these ‘breaches’ do not occur.

    Lorenzo is a broken system, it always was. The incessant mood music played in the trust is that Lorenzo is wonderful and being made better all the time. If it was so good people might actually be able to get things done with it instead of staring at frozen screens.

    Don’t expect any improvement in the service while Lorenzo is in place – every single trust that has deployed it has suffered massive productivity losses.

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