The Inquest found that within a crisis care plan compiled in February 2020, there was specific reference to expressions of concern on the part of the family being indicative of the deterioration of the deceased’s mental health.
Such concerns were raised on April 16, May 7, September 17 and November 3.
Those concerns were not followed up by the care coordinator and as such there was no face-to-face review of the deceased;
the family’s concerns were not escalated;
the follow-up appointment for the CTO due in October 2020 was not arranged;
the deceased’s care plan made no reference to the CTO or conditions;
the deceased was not seen by a mental health professional after May 2020;
for reasons unknown, neither the planned care coordinator contact on May 14 and November 24, nor any psychiatric review after April 9 took place;
supervision was either inadequate or non-existent.
All of which amounted to gross failings and as such, sub-optimal care.’
Daniel was admitted to the Meadowbrook mental health unit at Salford Royal Hospital for three weeks in February 2011 and the inquest heard that he had a total of eight inpatient admissions prior to his death.
Peta Pickering, a team leader for GMMH , told the court that they received a referral from the inpatient service on November 13 2018 and Reuben Pumbien was allocated as Daniel’s care coordinator on December 20 2018.
On April 15 2019, Daniel was discharged and given a community treatment order (CTO).
Dr Matthew Miller, a consultant psychiatrist at Cromwell House, outlined the four conditions of Daniel’s CTO:
- To reside at the designated property as agreed by GMMH
- To make himself available to the community mental health team care coordinator and psychiatrist
- To take prescribed psychiatric medications
- To make himself available with mental health checks and investigations.
In the six months between his discharge and October 12 2019, Daniel was only contacted by Mr Pumbien once – on August 22.
During the period of no contact, the inquest heard that Daniel wrote suicide notes and drank half a bottle of bleach.
On October 16 2019, Daniel’s case was escalated to the ‘red zone’ – meaning that he should have three contacts per week with his care coordinator.
Despite this, there was another period of no contact between November 20 2019 and April 7 2020.
On April 16 2020, Mr Pumbien spoke to Daniel and his mum Jennifer O’Neill.
She raised concerns that he was smoking cannabis every day and that he had been ‘neglecting’ his bedroom, but Daniel denied any deterioration in his mental health.
On May 7, Mr Pumbien spoke to Mrs O’Neill again and she told him that Daniel’s mood was up and down.
Between May 7 and September 17, there was a third period of no contact, even though Daniel should have been having weekly contact with his care coordinator during this time.
Mr Pumbien spoke to Daniel’s dad on September 17 and was told that his son was ‘monosyllabic’ and ‘distant’.
Assistant coroner Simon Nelson quizzed Ms Pickering about the care that Daniel received from Mr Pumbien.
She admitted that Mr Pumbien should have had more contact with Daniel.
Ms Pickering also admitted that her supervision of Mr Pumbien, from the date she started the job in June 2020, until Daniel’s death, had not been adequate.
The inquest also heard that there was a fourth and final period of no contact between September 17 and November 3.
Between these dates, Mr Pumbien was supposed to carry out a review into Daniel’s care but this was not completed.
On November 3, Mrs O’Neill told Mr Pumbien that Daniel was spending all the time in his room, had disengaged from the family, and wasn’t showing any motivation to do anything.
Ms Pickering told the court that this phone call should have prompted Mr Pumbien to visit Daniel ‘urgently’ but no one did.
Dr Miller added: “I think there is not much contact with him after my last review with him in April 2019. At that review there were concerns that he was using drugs and not engaging in much activity.
“I suppose looking back on things, I wish I had done more at that stage and wish there was more I could do. The Covid outbreak meant that the support services I can put in place didn’t exist. It was a difficult time but I think we should have seen him more often.”
Dr Miller admitted that after his review in April 2019, he asked for a six-month follow up in October but this did not happen.
“Do you know why it wasn’t arranged?” Mr Nelson asked.
Dr Miller answered: “The short answer is no.
“The long answer is I’ve searched through all the forms and there’s no evidence that form exists so it’s gone missing.
“I don’t specifically remember filling that form in but I fill them in every day so I wouldn’t remember that one in particular.
“That can’t happen and that shouldn’t be happening.”
Dr Miller added that the policy has since been changed.
Daniel’s dad found him hanged in their family home at around 6am on November 29
Following Daniel’s death, Nicola Whelan from GMMH wrote a root cause analysis report, in which she admitted that several mistakes were made by GMMH.
Mrs Whelan also revealed that a crisis care plan had been compiled in February 2020, which mentioned concerns raised by family members being indicative of a patient’s deteriorating mental health.
She told the court that a number of new measures have now been put in place to try and prevent any future deaths.
Reaching a conclusion of ‘suicide, to which neglect was a contributory factor’, Mr Nelson said: “The deceased had a long history of mental health illness with eight inpatient admissions.
“He was discharged from the Eagleton ward at Meadowbrook on April 15 2019 on a community treatment order with a requirement to attend Cromwell House on a regular basis for the administration of his depot injection, non-compliance with that requirement would result in a recall to inpatient service.
“Within a crisis care plan compiled in February 2020, there was specific reference to expressions of concern on the part of the family being indicative of the deterioration of the deceased’s mental health.
Such concerns were raised on April 16, May 7, September 17 and November 3.
“Those concerns were not followed up by the care coordinator and as such there was no face-to-face review of the deceased; the family’s concerns were not escalated; the follow-up appointment for the CTO due in October 2020 was not arranged; the deceased’s care plan made no reference to the CTO or conditions; the deceased was not seen by a mental health professional after May 2020; for reasons unknown, neither the planned care coordinator contact on May 14 and November 24, nor any psychiatric review after April 9 took place; supervision was either inadequate or non-existent.
“All of which amounted to gross failings and as such, sub-optimal care.”
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Source: Manchester Evening News, 23rd April 2021