A finding of neglect has serious repercussions in terms of reputational damage as well as potential criminal and/or civil proceedings with additional financial implications. This case highlights the steps care providers should take to avoid this outcome.
James Pollard was a 36 year old man detained under Section 3 of the Mental Health Act at Fromeside Hospital in Bristol, a medium-secure psychiatric unit. Mr Pollard had a long history of being treated by the psychiatric services and had attempted to take his own life in a serious incident which occurred six months before his death on 1 May 2013.
Mr Pollard was transferred to Fromeside Hospital in February 2013. Within a very short time there were two reported attempts at self-strangulation. Mr Pollard had a complex history and a diagnosis had not yet been firmly established but it was known that he would conceal symptoms from staff and act without warning. Mr Pollard’s care plan allowed him to have access to a CD player and attached cable in his room during the day. He was required to hand in both items at night. The care plan stated that if Mr Pollard presented as unsettled or voiced thoughts of self-harm he would not be allowed access to these items as they were identified as a hazard. Mr Pollard was on a 10 minute observation level whilst in his bedroom.
On 26 and 27 April 2013 Mr Pollard’s parents reported to ward staff based on telephone conversations that he was exhibiting signs of paranoia and presenting in the same way as immediately before his previous suicide attempt. Mr Pollard’s father was a retired GP who had worked in psychiatric crisis services, a fact which was known to staff. On 28 April 2013 the medical notes recorded that Mr Pollard had reported feeling paranoid, having “racing thoughts” and having slept badly. However, the care plan was not changed and Mr Pollard was allowed access to his CD player and cable. Later that day, Mr Pollard was found by staff in his en-suite bathroom with the electric cable around his neck.
Despite being resuscitated and taken to Frenchay Hospital, Mr Pollard never regained consciousness and died on 1 May 2013.
An Inquest held at Flax Bourton Coroner’s Court on 17-19 March 2014 returned a conclusion that “James Pollard took his own life, while the balance of his mind was disturbed, which was contributed to by neglect.”
An Inquest must take place where death is violent or unnatural or in all cases where the person is detained by the State, including under the Mental Health Act. The Inquest is a fact finding exercise, conducted in a public hearing by a Coroner, the purpose of which is to establish who died and when, where and how they came about their death. In certain circumstances, such as the case above, the “how” is widened to include “in what circumstances” and a jury is required.
An Inquest is attended by Interested Persons such as the hospital and family who can ask questions of witnesses. The Coroner or jury, directed by the Coroner as to the law, must then answer the questions set out above and come to a conclusion. It is not an adversarial process with competing “parties” and must not apportion blame.
There are a number of possible conclusions, including accidental death, suicide and unlawful killing. Where there is insufficient evidence to decide how the death came about an “open” conclusion may be recorded. In recent years, there has been an increase in the use of a “narrative”conclusion which is a brief neutral statement outlining the circumstances of the death. “Neglect” is not usually a verdict in its own right but can be added as a “rider” to other verdicts.
A finding of “neglect” in an Inquest is rarely used and considered to be very serious given that the purpose of Inquests is not to establish blame.
The test for neglect is that, on the balance of probabilities, the following points can be established:-
- The Deceased was in a dependent position where he could not provide for himself and
- There was a gross failure, that is one which was substantial and not trivial, to provide basic
- medical attention and
- The gross failure led to or contributed to the death.
There is no definition of what constitutes a “gross failure” but case law has established that it can include errors of judgment as well as direct acts or omissions.
Implications for providers
This case raises a number of important considerations for providers, the main of which are set out below:-
Information/warnings given by relatives must be taken into account and given the necessary weight – in this case staff said that they felt they were unable to act on the warnings given by the parents because the parents had asked them not to inform their son of their calls, on the basis that they wanted to maintain their son’s confidence and make sure he kept telling them how he was feeling. Staff said that they felt unable to act on the information because they did not want to breach confidentiality and would not be able to justify to Mr Pollard any increase in monitoring or removal of risk items. Two points arise from this:-
- Breach of confidentiality concerns should be discussed with the relative and it explained that it may be necessary to disclose the information where there is a serious risk of self-harm.
- A serious risk of self-harm will in any event outweigh breach of confidentiality
In addition, the evidence in this case was that staff made decisions based on Mr Pollard’s presentation to them, even though he was known to conceal symptoms, and did not give appropriate weight to the information from the parents and Mr Pollard’s history of self-harm.
The provisions of a care plan must be adhered to – in this case Mr Pollard was allowed access to the cd player and cable in his room to allow him to enjoy music as a means of “positive engagement.” However, in recognition of the hazards of these items, the care plan stated that the cd player and cable would not be given to Mr Pollard if he voiced thoughts of self-harm or presented as “unsettled.” This was either not considered or considered but the judgment made that there was no risk despite the evidence.
Consider whether more be done in relation to assessing and managing risks – it may be that there are ways of managing the risk at source. For example, one of the changes put in place at Fromeside Hospital following Mr Pollard’s death has been to shorten the electric cables. Consideration should also be given on the policy in relation to hazardous items to ensure it is consistent. In this case Mr Pollard was not allowed unsupervised access to art materials and a gift of a coaster but was allowed the use of an electric cable in his room.
Review the policy in relation to observation levels - NICE Guideline 25 on managing violence/self-harm sets out guidance on the appropriate observation levels and when they should be changed. In addition, specifically in relation to self-strangulation, the medical view is that there is between 3 to 5 minutes before brain death occurs and therefore a 10 minute observation level is not likely to be sufficient where this is a serious risk.
Review anchor points on an ongoing basis - Mr Pollard had tried on three occasions to self-harm using ligatures tied to the bathroom taps. Providers should ensure that they have a policy in relation to ligatures which is reviewed following any such attempts and changes made to risk assessments and care plans where necessary.
What to do next?
A finding of neglect has serious repercussions in itself in terms of reputational damage and may be followed by criminal and/or civil proceedings with additional financial implications.
A neglect finding often indicates systemic failings and a case such as this demonstrates the importance of reviewing policies and procedures in relation to risk assessment and management, observations, communications with relatives and adherence to care plans. It also highlights the need to ensure that staff receive regular training and supervision and this training is followed.