Her Majesty’s Assistant Coroner, Ms Rachel Galloway, concludes that the lifting of a mental health section was inappropriate and more than minimally contributed to the tragic death of Mr David Fowler

Monday 16 December 2019 to Friday 20 December 2019

David Fowler was 41 years old when he sadly died on Boxing Day 2018 after falling from a motorway bridge over the M6. At the time he was an informal patient at Transitional Rehabilitation Unit (‘TRU’), having been removed from his section the week before.

David had suffered a severe head injury in 2003, which left him with an Acquired Brain Injury (ABI). He had also struggled since adolescence with substance misuse issues. David has lovely, supportive and incredibly close family who fought his whole life to get him the help that he needed. Although they tried for years to care for him, due to his highly complex needs he spent much of his adult life subject to treatment in hospital or in the community under the framework of the Mental Health Act 1983.

In April 2017 David was accepted for a place at TRU, a specialist rehabilitation unit for those with acquired brain injuries. He spent time on the Newton Unit, the most secure, before moving to the Lowton Unit, and finally moving to Ashton Cross. However, he was kept under section 3 of the Mental Health Act with section 17 leave, with the conditions that he abstain from alcohol and illegal drugs, and reside at Ashton Cross.

During his time at TRU there were frequent episodes where David would leave the side unplanned and often be returned days later under the influence of drugs or alcohol by the police. He also had planned visits to see his family twice a week, where he would have dinner with them, watch TV, and attend Narcotics Anonymous meetings. David’s family were always involved with his care, and talked to him almost every single day.

When David would abscond from TRU and return under the influence, his risk would be assessed and often he would be returned to the secure Newton Unit for a period of time. In September 2017 David left the unit unplanned, and was later admitted to Aintree Hospital unconscious. It appears that David was on a bridge after using drugs with his friends, said that he would kill himself, and had slipped backwards, falling 6ft and hitting his head. Had he fallen forwards, it would have been 40ft onto railway tracks. He later reported that he had no intention of killing himself and had only been joking.

In August 2018, after spending some months at the Ashton Cross unit, David was returned to the Newton Unit at his own request for safety, saying he was having thoughts about jumping off a bridge, but saying he did not want to act on this.

David’s Responsible Clinician carried out a mental capacity assessment in relation to David’s capacity to make decisions about drink and drugs, which was, win the words of one witness at the inquest, ‘not very good.’ He concluded, minimal consideration as to the potential impact of his brain injury on his substance misuse tendencies, that David did have the capacity in relation to his substance misuse, At a Multi-Disciplinary Team (MDT) meeting on the 31st October 2018 TRUE made the decision that David was no longer suitable for treatment at the unit, and asked the Liverpool Community Mental Health Team (CMHT) to begin making plans for his discharge. David’s family were never informed of this and were unaware until the inquest that TRU had begun discharge planning at this time.

On the 7th November 2018 TRU sent an email to the community team stating that they could only manage David’s risk for a further four weeks, and requested that the community team make arrangements as soon as possible. David’s social worker made plain that she believed four weeks to be an unsafe timescale for discharge, due to David’s complex and various needs.

On the 7th December, David had turned up at his family’s house after he went AWOL from TRU on 6th December. David then left the house and ran to a nearby bridge. He climbed to the wrong side of the rails and was threatening to jump and had to be physically pulled down by two of his sisters and members of the public. Police subsequently attended. The family rang TRU to ensure that they were aware of this incident, but the during the inquest it was clear that TRU had not understood the facts properly, had not enquired further about it, not had they taken any appropriate steps to mitigate David’s risk on return.

An MDT meeting took place on 11th December 2018, with no staff member from the community team present. From minutes of the meeting, it appears the recent bridge incident was discussed, but that the focus of the meeting was on discharging David from TRU. Again, the family were not informed of these decisions, despite being deeply involved in David’s care and with David not objecting to information being passed to them.

During the inquest, all witnesses from the CMHT confirmed that correspondence from TRU was putting pressure on them to find a placement for David quickly, rather than properly assessing his needs and sourcing the most appropriate placement for him.

A further MDT meeting was held on the 18th December. David’s social worker again did not attend this meeting, but a colleague attended in her place. The family were not invited to, or informed of, this meeting. At this meeting the Responsible Clinician made the decision to rescind David’s section, agreeing that he would remain at Ashton Cross as an informal patient while an alternative placement was being sought. During questioning, all witnesses from CMHT confirmed that they were not previously aware that the purpose of the meeting would be to lift the section, and that they had all had the understanding that David would remain subject to the framework of the Mental Health Act whilst transitioning into the community. It was accepted during evidence that the social worker from the CMHT did raise objections in the meeting to taking David off section, but this was not recorded in the minutes. There is also no evidence that the ‘bridge incident’ the prior week was discussed with the community team.

It is the policy of TRU to inform the nearest relative when a change is made to the legal status of a patient at TRU. Informing the nearest relative is also a requirement of the Mental Health Act itself. David’s family were not informed that he had been taken off section, but instead found out by accident the following day when his mother called the unit to speak to David, as she often did. She was informed the following day when his mother called the unit to speak to David, as she often did. She was informed by a staff member that David was ‘out’, and when she asked how that was possible as he was under section, she was informed that he had been taken off section. David’s family were shocked and began to panic, as they had thought David was safe under section, and had been given no warning that he might be taken off. Without the framework of the Mental Health Act he could come and go from the unit as he pleased, was not subject to s.17 leave risk assessments and his Responsible Clinician was no longer informed about high-risk behaviour. His family called the unit multiple times trying to get in touch with the Responsible Clinician, speaking to various members of staff, but he did not get in touch with the family until two weeks later, after David’s death.

The Coroner heard evidence during the inquest that following David’s removal from section neither his care plan or risk assessment were updated. Staff seemed confused about when or if this should have been done, and assumed that his risk would remain the same, despite the care plan itself stating that his risk would increase significantly if no longer being treated under section. There was also confusion about how the decision was made to inform David’s family of the rescinding of the section, with one witness, the Acting Manager of TRU, insisting that she did make the phone call. However, this was not recorded anywhere in the care notes, and on the evidence of David’s family the Coroner rejected this witness’ evidence.

On the 20th December David left the site and was returned by police on the 22nd. However, police did not see that he went back to the unit, and David went missing again. David was found by staff at TRU on the morning of the 24th cooking, appearing to have returned in the early hours of the morning. Witnesses for TRU confirmed that, had he still been under section at this time, the incident would have been reported to the Responsible Clinician, his risk would have been assessed prior to him leaving and after returning, and that restrictions may have been put in place. As it was, no action was taken.

On the morning of the 26th December David appeared normal, making plans for the week. He asked to be taken into town to watch the races that afternoon, as this was an activity that he enjoyed. He was driven into town around 1:30pm and was dropped off at a pub. There was no set time for him to return to the unit, and the witness who drove him to town understood that David would be walking back later on his own. Around 3:30pm David was seen by members of the public to climb the wrong side of the guard rails on a motorway bridge over the M6. A few people stopped their cars to try and talk him down. David then held his hands out and fell backwards, landing on the hard shoulder of the motorway below. He was declared dead at the scene by emergency services, later confirmed to be of multiple injuries.

The coroner found that the Responsible Clinician gave confusing and at time contradictory evidence during the inquest. At times he did not seem to understand the difference between the Mental Health Act 1983 and the Mental Capacity Act 2005. He was unable to provide a satisfactory answer for why David’s section was lifted on the 18th December, and why David no longer met the criteria to be detained.

The Coroner instructed an expert Psychiatrist witness, Professor Shaw, to comment on the appropriateness of rescinding the section. She found that it was inappropriate to lift the section at this time, and that it would have been inappropriate to do so until there was a plan regarding David’s care plan going forwards and his community placement. Drawing on this evidence the Coroner found that the lifting of the section more than minimally contributed to David’s death, as the framework for assessing David’s risk was no longer in place, and there was no ability for staff to manage this risk as an informal patient. In addition to this, the impact that this uncertainty would have had on David’s mental state would like have been significant, as evidence was heard that David spoke to staff about his concern that he was going to be ‘turfed out’ and was confused about his future. Professor Shaw also found that the ‘bridge incident’ on the 7th December was not taken seriously enough by the staff.

At the conclusion of the inquest the Coroner found:

• Removing David from section 3 and therefore section 17 of the Mental Health Act 1983 on the 18th December 2018 contributed to his death eight days later
• It was a failing on the part of TRU not to invite the family or seek their views at the MDT meeting on 18th December 2018
• The information about the lifting of the section was not properly communicated to the family
• David did not make plans to end his life prior to visiting the bridge on the 26th December 2018, but that at the moment that he fell he did intend to end his life
• David’s capacity for decision making in relation to drugs and alcohol was never properly assessed

HMA Coroner Galloway has also issued a Regulation 28 Report, better known as a Preventing Future Deaths Report. This is in relation to outstanding concerns about communication with families, and how they will be contacted about important legal changes such as this. The Coroner noted that, despite a policy being drafted by TRU, she still has concerns about how this will be implemented, as during the inquest there remained confusion between witnesses, specifically the Responsible Clinician and the Acting Manager, about who was responsible for contacting the family.

HM Coroner also advised the Responsible Clinician to self-report to the General Medical Council, due to the evidence heard.

David’s family said:

“We are absolutely devastated by David’s death. He was an incredibly talented musician, had an amazing sense of humour, made friends wherever he went and we loved him very much.

As a family we fought so hard his whole life to get him the help that he needed, and finally thought that he had found this at TRU. We were shocked when we learned that David had been taken off his section, with no prior warning given to us. If we had known about this, we would have been taking action to find somewhere else for David, and made sure that he stayed safe. As it was, we felt powerless. It was heart breaking to hear the evidence of David’s Responsible Clinician during the inquest, as we thought he would be looking out for David, but we now know that he was not doing his job properly. We will never get over losing David, but feel that the inquest has brought him justice. Our hope is that no other family has to suffer in the way that we have, and that real change is made as an outcome of this.”

Jenny Fraser and Charlotte Halsted said:

“David had highly complex needs, and as a result needed constant support, either in hospital or in the community. It seems clear that TRU felt that David was becoming a burden for them to care for, but did not put in the time and consideration for where he would be placed. Despite a highly involved and loving family, TRU failed to involved them in the process. David’s family have shown incredible strength through this entire process, and continued to fight for David as they always had during his life. We are pleased that the Coroner has recognised the failings by TRU, and that she has taken further action by issuing a Regulation 28 Report and requesting that the Responsible Clinician reports to the GMC. It is so important that institutions like TRU take responsibility for their actions, and we hope that as an outcome of David’s inquest services at TRU will be made better for all those that they continue to serve.”