INQUEST REPORT

21^st May 2015

THE VERDICT

At West London Coroners’ Court today, the West London Coroner, Mr Chinyere Inyama, recorded a narrative verdict on my sister Rosemary’s death.  He told the Court that “she took her own life in part because the risk of her doing so was not adequately assessed. There were windows of opportunity which were missed.” He had heard from me, from Dr Peter Joseph her GP, from Dr Ben Lucas her Psychiatrist, and from two healthcare workers whose contacts were very brief – one a support worker and one the mental health nurse who was staffing the urgent advice line when I phoned them on 11^th January 2014, three days before she died.  Following the Inquest, I have received a public apology from Claire Murdoch, Chief Executive of Central and North West London (CNWL) NHS Trust, which you can find below, following my account.

Opening the proceedings at 10.10 am, the Coroner explained that Coroners’  Courts are the oldest type of Court in the country. The Court would have no interest in blame, or in any kind of civil or criminal offence. An Inquest is an inquiry into a death—who, how, when, and where. However, in a case such as this, he is required to issue a “PFD” – Prevention of Future Death Report, detailing the lessons which had to be learned.

THE EVIDENCE IN DETAIL

Mr Inyama expressed concern that one of the witnesses summoned, Pam Yates, was not in Court and had sent in a doctor’s note to say she was unfit for work due to an operation. The Coroner stated that such a note did not excuse somebody from attending Court. Being unfit for work did not mean you could not attend for an hour to give evidence.

I was called to the witness stand, and was asked to list my concerns about Rosemary’s NHS care. I listed (i) the ongoing treatment of her illness (ii) poor co-ordination and communication (iii) lack of continuity of care (iv) nobody from the team got to know her as a person and (v) not enough support or medical appointments.  I described Rosemary as generally a cheerful person. The chief symptoms of her depression were agitation, anxiety and memory loss. There is a well known type called “smiling depression” where a cheerful face can hide an underlying severe disease.

I told the court about her two suicide attempts when she had been an inpatient at the Cygnet Hospital Harrow in May 2013. She reported that she had tried to drown herself in the bath, but nobody witnessed this. The second attempt was when she was out with two nurses, and she had attempted to walk in front of a car or a van. After this she had been put under 24 hour observation during the last week of her stay there.

I also told the Court briefly about my letters of complaint, the first two in November 2013 asking for an urgent appointment for Rosemary, and stating she was at risk due to lack of support. As a result of this Rosemary was visited by two support workers on 10^th December 2013, who agreed to take her shopping and help plan her week’s menus. I explained Rosemary’s symptoms to them – agitation anxiety and memory loss, and one turned to the other and said “We never heard of memory loss being caused by depression.” This was annoying as it had just taken me three months to convince Rosemary she did not have dementia, and this had involved a referral to a private neurologist, Michael Gross and detailed testing by  neuropsychologist Professor Narinder Kapur, and they confirmed that her memory loss was due to depression and that she did not have dementia. The support workers took Rosemary shopping on December 18^th after which Rosemary told me they would not be taking her again. I was very annoyed and expressed this in a phone call on December 20^th and a longer letter of complaint dated 27^th December. Unfortunately by the time the Consultant returned from his Christmas break, the copy of my letter had been removed from the system by the management because it was marked “complaint”. Dr Lucas did not know the support workers had stopped seeing Rosemary by the time she died.

I was then asked about some of the events leading up to her death, and I talked about her visit to Northwick Park Hospital A and E on the morning of 14^th November 2013. Rosemary had phoned us at 5 am telling us that she was breathless, had rung 111, and that they were sending an ambulance for her. At 6.30 am Northwick Park Hospital phoned to tell me my sister was there, and enquiring “Is she well enough to go home on her own?” I told them I had no idea, and asked if they wanted me to fetch her, and they said yes. When I arrived she was on a drip, and I was told she was dehydrated. Why they did not treat this by simply giving her a drink is a mystery. I asked if she had had a mental state examination. I was told that they had phoned through to the Mental Health Liaison Team, but they had refused to see her “as she is a Hillingdon Patient.” On her discharge summary her diagnosis was given as “Mental Disturbance – Non-Specific: Depression.” Rosemary wrote across the top of her own copy a strange note. “I dialled 111 as I was breathing too fast & that was the only reason. Rosemary Hilton.” Why had she signed a note written to herself? What was she trying to remind herself of? It became clear to me when on Sunday 12^th January 2104 Rosemary told me on the phone that some weeks before (she could not remember when) she had tried to suffocate herself and permanently damaged her tongue.  After she died her friends told me she had tried to put her head in a plastic bag. This made sense of the note she wrote, if that episode had taken place early in the morning she went to A and E.

At this point the Coroner interrupted me to say “we are now moving into the realms of speculation.” Nevertheless, my interpretation was accepted by other witnesses.

I then talked through the events of the last days of Rosemary’s life. 11^th January  2014 was her birthday, and we took her out to tea at a Hotel. Rosemary was functioning well enough to be able to organise a cab and get there on her own. When I took her home afterwards, she asked me in and then was reluctant to let me leave. She told me she had not enjoyed the tea because she was unable to taste anything because of a lesion on her tongue. For months past, going out for meals had been the only enjoyment in her life and now even that was taken from her. She went on say she had something to tell me which I would be very shocked about. She was reluctant to say more, and it took me an hour to tease it out of her, but then she said she had made several suicide attempts in the past week. She then became distraught, crying out “I want to die, I want to die.” I phoned home to ask for advice and Claire suggested I try to find out if she was in immediate danger of self harm. I did not feel competent to do that so I thought of taking her to A and E. However, this would not have been easy. Firstly, she was reluctant to go, and if we had gone she would have insisted on packing two large suitcases first. Her main activity over the preceding weeks had been packing and unpacking these suitcases, believing that she was going to get locked up in hospital and the key thrown away. Even more importantly, I was by no means certain she would be admitted to hospital, particularly after the experience at Northwick Park. By then it would have been the middle of the night and what would I have done with her? So I took her crisis card, and phoned the number she had been given in front of her. To my shock I only got a voicemail message. I left a very clear message telling them I was with my sister and she had been making suicide attempts.  I waited with Rosemary for a further 75 minutes but nobody phoned back. By then she had calmed down and I felt it was safe to go home. When I got home, I rang her at once to ask if they had phoned back. She said “Yes, and I told them I’m all right now.”

The following evening, 12^th January, was the night Rosemary told me about the suffocation attempt some weeks earlier. I felt this had to be reported as well so I phoned the Pembroke Centre on the following morning and spoke to the Duty Officer Pam Yates. She was sympathetic and told me she would speak to Rosemary and then phoned me back. When she did so she left me a voicemail message, and I asked permission to read my transcription to the court. This was refused, so I summarised it by saying she was concerned about Rosemary’s safety and would discuss it at their team meeting the next day. However that team meeting still did not propose any action. That was the day Rosemary died, though they had not heard the news when the meeting was held. The night before (13^th January 2014) I had asked Rosemary about what she had told Pam Yates. Had she told her she had no intention of self harm? “What I told her,“ said Rosemary, “ was that I had run out of ideas.” I was asked if I thought Rosemary was in immediate danger. I replied that she certainly was in danger, but I did not think the danger was immediate because I would never have left her alone in her flat in that case. I knew she would not take an overdose – she was scared what would happen – and the thought never entered my head that she might be at risk because she lived on the third floor.

On Tuesday 14^th January 2014, I was phoned at 8 am by David Mattison, who was at that time Company Secretary to the block of flats where Rosemary lived, and by coincidence one of the co-ordinators of my volunteer synagogue care group. He knew about Rosemary’s condition and of my involvement and concern. He told me that he thought there had been a stabbing and lots of police were around the area where Rosemary lived. He suggested I ring her to reassure her as she would be worried. I phoned repeatedly but only got voicemail. I decided not to go round there as I was told the whole area had been cordoned off by police. I did not go to work but stayed at home until I could find out more. At 10.30 I dialled 101 and explained who I was and that I was worried about my sister. At 11.30 the police phoned back and said they wanted to visit me: a person had been found severely injured on the ground outside Rosemary’s flat: a window was open: the police had broken into the flat and found it empty. I said that had to be Rosemary but they would not confirm that. When the police arrived at 1.30 they told me the person they had found had subsequently died in hospital.

Charlotte Thrale, Paramedic, then gave evidence of how Rosemary was found lying on the ground severely injured at 7 am on Tuesday 14^th January 2014. She was taken to the major trauma unit at St Mary’s Hospital Paddington, and despite efforts to resuscitate her, died there at 9.40 am that morning.  DS Joe Garrity described the police action on the day. They noticed a window wide open above where Rosemary had been found injured, which was strange because it was a very cold January morning. They broke into the third floor flat and found nobody there. A chair had been placed under the open bedroom window and there were slippers underneath the chair. A depression in the middle of the chair showed where she had been standing, and fingerprints, shown to be identical to the body, revealed where she had gripped the window. There were no signs of a struggle. Everything pointed to the conclusion that Rosemary had jumped deliberately from the third floor window of her bedroom. “There was nothing I witnessed to suggest anything other than a suicide.” However, while this was all being investigated, the extent of her injuries meant that at first this was treated as a possible murder enquiry, with a wide police cordon and many officers involved.

The court then heard from Dr Peter Joseph, Rosemary’s GP, who described one by one all his contacts with her from December 2012 until the time of her death. In December 2012 he noticed she was exhibiting psychotic symptoms, and he knew from her history she had had a previous episode in Canada which had been treated with amitriptyline. On this occasion he had referred her to a private psychiatrist, Dr Sue Thomson, who had admitted her to the Priory Hospital. On discharge she was much better, and remained so until March when she started to become very depressed. Dr Thomson then admitted her to the Cygnet Hospital in Harrow.  Later on Dr Thomson needed Dr Joseph’s help to get Rosemary transferred to the NHS – they would not take a direct referral from a private psychiatrist and so she had to go through the GP. Dr Joseph went through Rosemary’s drug regime during this period, tracking the changes – from olanzapine, to respiridone, to pregabalin, and then to sertralin,.  Dr Joseph stated he received a discharge summary from Dr Thompson, and her diagnosis as given there was “severe depression.” On discharge from Hillingdon Hospital later, her diagnosis was “delusional disorder (provisional diagnosis), bipolar disorder current episode severe with psychotic symptoms (principal diagnosis).” [In October the diagnosis was changed to “delusional disorder” and in December to “depressive episode, unspecified.”]

Rosemary resumed her visits to the surgery when she left Hillingdon Hospital. At first she was being looked after by the Home Treatment Team. In response to questions about the information available to him, Dr Joseph responded “I don’t think I’ve ever been contacted by the Home Treatment Team” and added “Some rationale would have been helpful.”  After Rosemary’s discharge there was a two month gap (July – September 2013) before the Hillingdon Recovery Team based at Pembroke House Ruislip took over. Dr Joseph was concerned by this gap in treatment, but did not take action himself because Rosemary was able and willing to chase up her appointment herself.  At this time Rosemary was prescribed and was taking Olanzapine, respiridone and venlafaxine, a combination described by the Coroner as a poly-cocktail of drugs. However, the respiridone was removed in September, and the olanzapine at the end of October, because Rosemary was complaining of side-effects. Her condition deteriorated and gave such cause for alarm that the GP wrote to Dr Lucas on 8^th November requesting an urgent medical appointment. The letter was read to the Court – Rosemary appears to being going downhill – she lacks motivation – please make contact with her, or she may well end up back in hospital. No reply was received and the appointment scheduled for 10^th December was not brought forward.

From November onwards Rosemary visited the surgery frequently complaining of a variety of physical ailments. Dr Joseph considered that some of these, particularly her urinary symptoms, were part of her mental health condition. These visits to the surgery continued until her last visit on 6^th January 2014, when she seemed a little more cheerful and “marginally better.”

Questioned about his contacts with the Hillingdon Recovery Team, Dr Joseph told the court he got reports after each out patient appointment, though not immediately. He would have hoped that Rosemary had more frequent out patient appointments, and was surprised that no follow up was arranged after the discharge by the Home Treatment Team. Asked if his contacts with the Recovery Team were adequate, he replied that they were “typical, not adequate,” and that Rosemary required more support.

The Court then heard from Margaret Hester, support worker, who described her two meetings with Rosemary on 10^th and 18^th December. The support workers’ role was simply to do practical tasks for patients. In advance of the meeting the two of them read up her social care notes, but not her medical notes. When they arrived at Rosemary’s flat on 10^th December, chairs had been laid out in a circle, with items on each chair, as if for a larger meeting. The flat was in immaculate condition. It was agreed to take Rosemary shopping once a week, but when they did this on 18^th December, Rosemary appeared bright and cheerful, well able to find her way round the supermarket, and in any case she already had a fridge and freezer full of food. Margaret and Angie then discussed this with their supervisor who agreed this was not an appropriate way forward, and they would have to find some other way to support Rosemary.

The next witness was Olanike Ojutalayo, a Mental Health Nurse who was manning the Urgent Advice Line on her own when I called on Saturday evening 11^th January 2014. She was unable to take my call directly as she was on another call at the time. When she phoned back, Rosemary told her she was fine and felt safe. On enquiring if I was still there, she was told I had gone home. On enquiring why I had left a message about suicide attempts, Rosemary replied that it was “just a spur of the moment thing and of no importance.” Under questioning, Ms Ojutalayo stated “I can only go by what Rosemary said to me.” Asked about background information, she said she had access to patients’ notes, but it was not her practice to read them before speaking to patients, as the priority was to make the call. Therefore she had no knowledge of Rosemary’s earlier documented suicide attempts. On being asked if she read the notes after the phone call, she stated that she had skimmed through them, but this did not prompt her to take any further action, other than the standard practice of emailing the Hillingdon Recovery Team so that they could pick up the message on Monday morning. Asked what further steps were generally available to her, she stated that when necessary she would call an ambulance, and then phone ahead to A and E to tell them a patient had been referred and was on the way.  She was able to do this if necessary even if the patient did not request that course of action. She did not judge that to be necessary in this case.  When questioned, she appeared to be unaware that the age of the patient might be a significant factor.

The Coroner then read brief summaries of the toxicology and post-mortem reports, indicating that Rosemary was compliant with her medication, as venlafaxine was found in her blood stream, and that her injuries were consistent with falling from a height.

Dr Lucas, Psychiatrist, then took the witness stand. He was asked how many times he saw Rosemary, and was unable to give a clear answer. He was  asked why he did not bring forward his appointment with her from December to November when asked to do so by Rosemary, and in letters from me and her GP. He replied that he thought talking to her on the phone was a sufficient response and mentioned GMC guidance on phone consultations.

He was then asked what her condition was, and he replied that he had a working diagnosis of “depressive disorder.” Asked about the treatment for her condition, he replied that it was threefold (i) Social “I increased the support for her” (ii) Medical – antidepressants and (iii) Psychological – “My aim was to build a therapeutic relationship, so she would trust me.” Asked about the support workers he said they were meant to provide health and social support as part of the therapeutic package, which did not fit with Margaret Hester’s evidence that they just did practical tasks. Asked about their withdrawal from visiting Rosemary on 18^th December, he replied that he was not made aware of that until after Rosemary died.

On his relationship with Rosemary, Dr Lucas stated “she did find it difficult to be open with me”, and added that “Rosemary wasn’t easy to get to know,” and “wasn’t easy to access”. “Was Rosemary Impulsive? “ “Yes.”

Dr Lucas was asked about previous diagnoses, and stated that he never received a discharge summary from the Cygnet Hospital.  It is apparent that he made no effort to obtain one, because the GP had stated in his evidence that he had the discharge summary.

Asked directly if when Rosemary died she was “floridly and severely depressed,” Dr Lucas replied “no.” Asked by the coroner if at the end of her life Rosemary was low risk, medium risk or high risk, Dr Lucas avoided the question and did not give an answer.

Dr Lucas was asked about the episode at Northwick Park Hospital on 14^th November, which had been noted on the record as a “panic attack.” Had he taken this seriously? Had he asked her about it? The answers were noncommittal.

On 10^th December Rosemary gave Dr Lucas a full page written account of her symptoms, including the words “I have never been as bad as I am now.” Dr Lucas was asked if that phrase rang alarm bells, and he said that it did, but this did not alter his treatment plan.

Because of the concern expressed by the gap between appointments, Dr Lucas asked Rosemary how long she thought there should be between appointments, and she replied four weeks. Unfortunately this was written down as “next appointment next month” instead of “four weeks” so the next appointment was sent for 27^th January. Dr Lucas added “Whether this would have made a difference, I do not know.”  Asked why he did not ask her about thoughts of self harm on 10^th December, he agreed that he had not asked this and added “It would have been better if I’d asked her.”  Asked about the paucity of risk assessments, Dr Lucas replied that it was not his practice to do these every time, only if there was a “risk event.”  It wasn’t necessary to do more, because she had contact with the duty team. This was acceptable “in terms of the Risk Policy.”

Asked why Rosemary was on the “Lead Professional Care” approach and not the “Care Programme Approach “(CPA) which would have provided a care co-ordinator other than him, Dr Lucas made light of the difference, stating that it did not mean she would have been seen more often. With the integrated disciplinary team, whether under LPC or CPA, a social worker has to do the required health and social care assessments himself. He accepted that he had not specifically informed Rosemary or me that he was her key worker.

Dr Lucas was asked why his letters could take up to three weeks to reach the GP, and he blamed the lack of admin staff available. He also stated [incorrectly] that  he had had several long telephone conversations with me. He came close to suggesting that I took up valuable time in his consultations he could have spent with Rosemary. The coroner asked, in that case, why he didn’t ask me to leave the room.  He agreed that might have been a good idea except that Rosemary wanted me there. He stated (as if it was important) that Rosemary had herself agreed to coming off Olanzapine, but accepted it was his clinical decision.

In the absence of the witness Pam Yates, Dr Lucas answered questions about the Risk Assessment she conducted over the phone with Rosemary on 13^th January 2013, the last person from the Team to speak to her. Dr Lucas explained that her notes were reviewed in the MDT (Multi-Disciplinary Team) meeting on 14^th January, a large team with generally around 12 members and two consultants. The conclusions of that meeting were that the crisis line contacts should be reinforced and Gina Duncan of the agency DASH should when possible do a personal budget assessment for Rosemary. It did not matter that Rosemary had funds of her own, because the personal budget assessment was still the route in to getting social care.

The final witness was Steven Howson, co-author of the official Trust RCA (Root Cause Analysis) Report by the Trust into Rosemary’s death.  He was prepared to answer questions on the Report, but the Coroner wanted to know which of the recommendations had been implemented. Steven Howson said he was not able to answer that, so he was quickly dismissed from the witness stand. That completed the evidence presented in Court. After delivering the verdict as headlined above, the Coroner cleared the Court at 2.10 pm.

THE RCA REPORT

Steven Howson’s abrupt dismissal from giving evidence means that the findings of the official Trust review were not aired in open court, although they are now part of the official documentary evidence for the Inquest. I therefore append here the recommendations from that report, which was completed in June 2014. You can read in the comments section below the NHS progress report as given by their press office in August 2015.

1. Hillingdon Recovery Team (HRT) needs to implement a clear system of managing complaints and formal correspondence. All members of the team should have training on the CNWL complaints policy.

2. Hillingdon Mental Health Services need to implement regular clinical interface meetings between Acute Services (including Inpatient Services and Home Treatment Team) and HRT in order that all potential referrals into HRT are discussed and the appropriate level of care is agreed, maintaining continuity of care between Service Lines and adhering to Admissions/Transfers and Discharge and CPS policies. Problems highlighted regarding resources and allocation of care co-ordinators should be reviewed urgently by HRT.

3. Decisions regard the appropriate level of care need to be clearly formulated with reference to all available clinical information and recorded in the clinical records. Increased duty contact, concerns from carer or escalating risk concerns need to be clearly communicated to the Lead Professional or Care Coordinator and the level of care reviewed/recorded.

4. Hillingdon Mental Health Services require clear systems to identify carers and to offer them carer’s assessments and support in lien with statutory and local policy requirements.

5. HRT should review the duty system to ensure that there are clear and robust systems in place to manage clinical risk and communicate salient clinical information between professionals within the team.

6. HRT need to demonstrate that all staff are meeting the requirements of the CNWL Clinical Risk Assessment Policy. The quality of risk assessments and risk management plans (both JADE risk documents and progress notes) require urgent review measured by a team audit and staff training where appropriate.

7. All recommendations formulated by Northwick Park Psychiatric Liaison Team following referrals from Accident and Emergency should be evidenced, recorded and wherever possible based on face to face assessments.

8. Subject Access requests of a sensitive nature need to be overseen by a manager to ensure all the relevant clinical information is provided and that any support needed in reviewing those records is offered, including waiving the financial charges for access to the records.

9. Formulations including the rationale behind diagnostic and treatment changes need to be clearly recorded in the clinical record and relevant clinical correspondence to other clinicians including GPs.

Following the recommendations is a list of action points. On point 7 the action is: A memo will be sent to all staff confirming that all patients that are referred to Liaison Psychiatry must be seen within one hour of referral from the A and E department. If a patient is not seen for a face to face assessment that case must be escalated to the nurse in charge at the time or the service manager at the earliest opportunity.

All staff will be briefed on this report and the clinical issues that were evident in this case.

READ MORE: Rabbi Michael Hilton talks to Caron Kemp about his mission to find justice for a sister failed by the system  July 2015

Rabbi hopes for changes in mental health services after sister’s death, August 2015

In Memory of Rosemary – a thought from Michael

Note added 14^th January 2023

It is nine years ago today that Rosemary jumped from her bedroom window to her death. Three days ago she would have been 70. The memories are as vivid as ever of the birthday tea back in 2014 which she complained that she could not taste properly, of that evening with her shouting at me “I want to die”, and of how I had not been able to get help for her. I thought I would try to find out what became of Dr Ben Lucas, her psychiatrist. His employers, CNWL NHS Trust, put him under special supervision for a while, and he then left the NHS and took up private practice, and then spent a couple of years working in New Zealand. On his return, he got another job back with CNWL and is currently working at Feltham Young Offender Institution, where he holds a post of Consultant in Offender Care. He also offers his services to a private business, Allen Associates, as an expert witness. On their website he states that he has given evidence at inquests where adequacy of psychiatric care is raised. He certainly has! I hope he has learned from his mistakes.

I have an abiding memory of visiting him, with a psychiatrist friend after Rosemary died. My friend asked him about his fateful decision to take Rosemary off the drug which was keeping her stable, Olanzapine, on October 31^st 2013. Dr Lucas said she had been prescribed the drug for psychosis and explained at length why he reasoned she was no longer psychotic. He then went on to say that he thought she might be bipolar and was planning to investigate this at her next appointment. At this point, my  friend intervened and asked, “If you thought she was bipolar, why did you take her off Olanzapine? It’s used as a mood stabiliser as well.” Immediately Dr Lucas’ face fell. His jaw dropped and his eyes widened. He gulped, but he answered not a word.

Right now, instead of the 70^th birthday party and celebrations we would have had in the last few days, there are just these difficult memories, the sadness and the anger. It is tragic now to hear of NHS patients dying at home, in ambulances, and in hospital corridors because the service is overwhelmed. There is a statutory duty of care. More cases need to be brought to hold NHS trusts and GPs to account, and the coroners’ system needs to be improved so that recommendations are enforceable. To find Rosemary’s story you shouldn’t need to have to visit this web page. There should be much more publicity of such cases and much more action to learn the lessons.

On the private psychiatry website Clinical Partners, Dr Lucas is praised in these words:

“Recognised by his peers as being highly dedicated, hardworking and knowledgeable, Dr Lucas has great communication skills, is a good team player as well as having excellent clinical acumen. He is open and honest, flexible and kind, demonstrates full professional integrity and has a warm, empathetic manner.”