NSFT PFD – Report 2: Sebastian Davies 2012

Here is the second PFD (Prevention of Future Death) report, in our series of 30 that have been issued by Coroners, relating to NSFT since 2012. We are publishing these one at a time to honour each person who has died. A Freedom of Information request means that we have NSFT’s PFDs and the trust’s responses to them. We have been looking for the patterns and themes that characterise the issues at NSFT. The errors they repeat, the promises they make (and break), the lessons they could learn.

*Trigger warning*

Who was Sebastian and what happened to him?

Sebastian Vaughn Davies was 23 when he died. He was detained under the Mental Health Act. On 24^th July 2012, he was assessed for unescorted s17 leave from the Norvic Clinic. On his return, no illicit substances were found on him but following morning he was found unresponsive. He was taken to the Norfolk and Norwich University Hospital and he died there 11 days later.

We would have liked to say something about Sebastian as an individual. However, we could not find any media reports about him. This could reflect a societal lack of interest in his death. He was a young man detained in a forensic mental health setting who died due to an overdose of opiates. We would argue that there are many young men like Sebastian, who are at elevated risk of dying, and that it is the duty of mental health services to keep them safe. We should be interested because every life has value.

You can view Sebastian’s PFD on the Ministry of Justice website here: https://www.judiciary.uk/publications/sebastian-davies/

Summary of the PFD:

In March 2014, Norfolk coroner, David Osbourne delivered a narrative conclusion: “Sebastian Davies died due to an excess of opiates obtained from an unknown source. We believe that procedures operated at the Norvic Clinic could not have prevented his death”.

However, the coroner noted that hourly observations during night (shining torch through door) were insufficient. There was no method for checking Sebastian’s movement (a lack of which could indicate that he had become unconscious) because different people were undertaking observations and therefore there was no continuity. Therefore, in the PFD the coroner ruled that NSFT needed an observation processes that ensured movement was monitored during night and there was continuity of observations.

The key points in NSFT’s response:

Andrew Hopkins (NSFT CEO at the time) responded by stating that a procedure including a form, with codes to show movement, would be used. He stated that it would not be possible for single person to undertake observations.

In his response, Hopkins, does not offer any apology or suggestion of regret.

Our analysis:

An overarching theme of failing to assess and manage risk features in nearly all the PFDs issued against NSFT over the last few years. A lack of clear and appropriate policies and procedures comes up again and again. In this instance the staff followed the policy but the policy was flawed. This seems to be a ‘quick win’ for the trust. They repeatedly state through the years that they will create a policy, procedure, or form. Easy. Sorted. Except the policies need to be sound and to be implemented if they are to be of any use.

Sebastian’s death was one of a cluster of deaths that occurred at NSFT in the wake of the disastrous radical redesign in 2021. Whistleblower, Dr Minh Alexander, wrote a report that outlined her concerns (which included the death of Sebastian). Tom Bristow, of the Eastern Daily Press, reported on this. You can see this here: https://www.edp24.co.uk/news/health/concerns-raised-over-deaths-at-norfolk-and-suffolk-mental-health-890026

As the deaths continued, what Dr Alexander and Tom Bristow reported would be replicated many more times. It was as if no one was listening.

Our campaign and the local media have been trying to alert people to the numbers of deaths at NSFT for years. See this blog from 2014: