Mental health trust under fire again after second man falls to his death at the Castle Mall
10:14 18 July 2014
The failings of a mental health trust have again been highlighted after a second man fell to his death at a city shopping centre in less than a year.
Concerns over services
The death of Luther Benjamin Hughes is, tragically, not the first and will not be the last inquest to feature Norfolk and Suffolk NHS Foundation Trust failings this year.
Fears were raised about the safety of mental health services last year after a radical redesign of services began to be implemented, which included a reduction in bed numbers and almost 200 voluntary and compulsory redundancies.
In October, a review was ordered after the unexpected deaths of 20 mental health patients between April and August last year, which prompted the launch of the EDP’s Fighting for the Vulnerable campaign.
Community teams at NSFT have reported high caseloads and more than 100 mental health patients had to be sent outside Norfolk and Suffolk last year because there were no acute beds available.
Luther Benjamin Hughes, 39, of Music House Lane, died from multiple injuries following a fall from an upper balcony at the Castle Mall on March 6 this year, less than a year after Matthew Dunham, 25, jumped to his death on May 9, 2013.
The then coroner, William Armstrong, criticised Norfolk and Waveney Mental Health Trust for its support of Mr Dunham which he described as “fragmented and uncoordinated” during an inquest in September, with two mental health staff who were seeing Mr Dunham at the same time not aware of each others’ involvement.
The coroner also expressed concern that an emergency GP referral that should have been followed up within four hours, instead took two days. And today, more concern was raised about the treatment given to Mr Hughes, who had a history of mental health illness and had been diagnosed with schizoaffective disorder, particularly the lack of communication between those responsible for his care.
An inquest held in Norwich yesterday heard Mr Hughes’ condition was exacerbated by him drinking alcohol, which started being a problem from 2002 when his mother died.
Mr Hughes, who used alcohol to “help with his illness and help him cope with life”, sought help from the Norfolk Recovery Partnership for his alcohol problems in August 2013 after being admitted to Hellesdon Hospital as an inpatient after self-harming.
After being discharged from hospital, there was no formal care plan in place for Mr Hughes, who was known to the Norfolk and Suffolk NHS Foundation Trust, although he did continue to get help from both the trust and Norfolk Recovery Partnership.
Since August 2013, Mr Hughes was visited regularly by Andrew Jones, a community support worker from the Norfolk and Suffolk NHS Foundation Trust, who he told he wanted help to tackle his drinking. Mr Jones said he “increased his visits” towards February/March this year as he was “picking up that he needed more support”.
The inquest heard that it was not passed on to the Norfolk Recovery Partnership that Mr Hughes had stopped taking his medication or that, on one occasion, Mr Hughes had told Mr Jones that he had taken cocaine.
The inquest heard that following Mr Hughes’ death the trust itself conducted an investigation which identified a number of issues with his care, including:
■ No evidence of a care plan.
■ No evidence of a multi-disciplinary risk assessment or a crisis plan.
The trust has since come up with recommendations to stop things like this happening in future, including:
■ Community mental health teams to review cases of service users with enduring mental health problems who struggle to engage with them.
■ Putting in place a new software system to ensure that other agencies, like Norfolk Recovery Partnership, will be able to access information about patients being treated.
Norfolk coroner Jacqueline Lake said there were concerns that had been raised during the inquest.
She said: “My main concern was in regard to a lack of communication between the trust and Norfolk Recovery Partnership” adding “there was no discussion between them or they were not aware of what the other knew or was thinking”.
But Mrs Lake recognised the trust had made recommendations following an investigation which took place after Mr Hughes’ death.
Recording a narrative conclusion, Mrs Lake said: “On March 6, 2014, Luther Benjamin Hughes was seen to voluntarily topple over the railings of castle mall shopping centre and died as a result of his injuries.
“His intention at the time is not known as he was suffering a mental illness at the time of his death and was under the care of mental health services.”
The inquest heard that no-one saw Mr Hughes fall, but he was picked up on CCTV.