Death 31.05.2023
Inquest: 18 and 19 September 2024 and 2 October 2024 at Nottingham Coroner’s Court
Coroner: Assistant Coroner Sarah Wood
Finding: Shortform conclusion of drug related death – more likely than not contributed to by failings of the Trust (Nottinghamshire Healthcare NHS Foundation Trust)
Represented by: Greg Almond, Partner and Solicitor, Rothera Bray LLP Solicitors (Serious Injury and Clinical Negligence Team) g.almond@rotherbray.co.uk
Abagail Clarke, Solicitor, Rothera Bray LLP Solicitors (Serious Injury and Clinical Negligence Team) a.clarke@rotherabray.co.uk
Cassandra Williams, Counsel, The Ropewalk Chambers, Nottingham clerks@ropewalk.co.uk
James Southern, known affectionately as Jimmy, was a son, brother, doting father, grandfather and husband-to-be, with a smile that lit up any room. He is described by his family as someone always on the side of the underdog and hated injustice. He was, in short, deeply loved and admired by those around him. His loss has therefore left a considerable hole in the lives of his friends and family following his untimely death on 31 May 2023.
Sadly, Jimmy suffered over the years with his mental health and often felt this was because of a motorbike accident he had many years ago, which left him badly injured.
His mental health declines were made worse during times of stress and as a result, he became known to local mental health services, most recently in August 2022 when he presented to QMC suffering from hallucinations. It was determined he was experiencing drug-induced psychosis and was sectioned under the Mental Health Act and admitted to Highbury Hospital in Nottingham. Jimmy remained an in-patient at Highbury Hospital from 9 August 2022 (overseen by Nottinghamshire Healthcare NHS Foundation Trust) until his discharge on 1 September 2022.
Jimmy should have been, at the point of admission on 8 August, referred to Rushcliffe Local Mental Health Team. Unfortunately, this was not done and he was incorrectly referred to County South Local Mental Health Team.
Review of Jimmy’s patient records revealed that it had been inaccurately recorded, in a number of entries, that a Community Care Coordinator (CCO) had been allocated when in fact it he had not and it would not be until 12 October 2022 that a CCO was allocated to Jimmy. It was 9 days before the CCO made the first (but unsuccessful) attempt to contact Jimmy, and another 10 days thereafter before contact was finally made.
Throughout Jimmy’s time as a community patient under the care of Rushcliffe LMHT, there were a number of considerable delays between his contact with his CCO, including no contact at all between 18 November 2022 and 16 January 2023 and again between 6 February 2023 until his death on 31 May 2023. The latter period occurred as a result of his CCO having gone on long term sick leave. No cover was arranged for Jimmy in her absence and his CCO made no attempt to contact Jimmy on her return on 3 May before his death on 31 May.
Jimmy’s records also show that inadequate risk assessments were carried out after his discharge from Highbury Hospital on 1 September 2022 and no medication review was carried out by his CCO, despite Jimmy presenting with a declining presentation in his final two meetings and informing his CCO he had been bulk taking his medications again.
Sadly, Jimmy was discovered by his father on 31 May 2023. The cause of death was determined as polydrug toxicity – an accidental overdose.
In her conclusion, Assistant Coroner Sarah Wood determined at the conclusion hearing on 2 October 2024 that the basic standards were not met and that patients and their families deserve better. The pattern of inaccurate record keeping was also highlighted as a grave concern together with the apparent failures in communication between patients and clinicians. A Prevention of Future Deaths Report has therefore been issued to the Trust.
Clearly, it is a hard conclusion for the family, but they nonetheless wish to express their thanks to the Coroner and their officers for their time, care and attention in closely examining the circumstances which contributed to Jimmy’s death.
Greg Almond, Partner and Solicitor at Rothera Bray LLP said:
“Jimmy’s family are devastated by his passing, particularly as he leaves behind children and a grandchild, all of whom he loved and adored deeply, along with a fiancée whom he was due to wed in December this year and both of his parents. Despite the gravity of their loss, they have shown great strength and dignity in their efforts to ensure Jimmy’s death was fully investigated. We are grateful that the circumstances leading to it were analysed and investigated thoroughly and the family only hope that lessons can be learned, and further families are spared the tragedy they have had to endure.”
Press enquiries to:
Susan Wilkinson and Grace Mason
Rothera Bray LLP
s.wilkinson@rotherabray.co.uk / g.mason@rotherabray.co.uk
Direct Tel: 0115 666 6916 / 0116 204 5357
