12 March 2017

Before HM Senior Coroner for Somerset Tony Williams
Opened 26 February, concluded 9 March

The inquest into the death of Robin Richards has concluded with the jury finding widescale failures in care contributed to his death on 3 July 2015. Robin, 33, was found hanging just over a week after his admission to Highbridge Court, a Tracscare run care home in Somerset. The coroner indicated that he will be sending a Prevention of Future Deaths report to the Department of Health around the lack of provision of suitable placements for people with Asperger’s, and to Somerset Partnership NHS Foundation Trust (SOMPAR) for failing to provide evidence of action taken to rectify their failings relating to Robin’s death.

Robin, 33, had multiple needs arising from mental ill health and other conditions including Asperger’s. He had been sectioned three times in the final 2 years of his life. Robin’s placement at the recently-opened Highbridge Court was arranged by SOMPAR. He arrived on 15 June, after being transferred from a local mental health ward where he had been an informal patient. He died in hospital four days after he was found hanging in the home on 29 June. Robin had made multiple attempts at self-harm prior to this, by running into moving traffic. The inquest heard that neither the care coordinator or the family were informed of all of these incidents. Despite Robin expressing suicidal thoughts, the care coordinator kept his risk classification as ‘low’.

The jury concluded that the cause of death was hanging, and that Robin had intended this to be fatal. They found the issues contributing to his death included communication; training; information sharing; discharge planning; care planning; and risk assessment. Robin was high functioning, but he was vulnerable, impulsive, and needed structure. He was transferred from Rydon Ward, where he was an informal mental health patient, to Highbridge Court, a residential transitional service for people with complex mental health needs run by Tracscare (who have since changed their name to ‘accomplish.’).

Staff from Tracscare gave evidence stating they were not aware of Robin’s risk of suicide and self-harm prior to accepting him into their care, and had not spoken to Robin’s clinician. Across the two week hearing, the jury also heard evidence that:

• Support staff left alone with service users on the day Robin was found hanging had no Asperger’s training and no training as to what to do in the event of someone found suspended/hanging.
• No ligature risk assessments were undertaken by Tracscare and no ligature cutters were available at Highbridge Court.
• An independent expert gave evidence that a service like Highbridge Court, advertised as a specialised forensic mental health care home, should have been live to the possibility of suicide and self-harming behaviours.

Highbridge Court had recently opened, and had not yet been inspected by the Care Quality Commission (CQC) at the time of Robin’s placement. Within weeks of Robin’s death a CQC inspection found the home was unsafe. The Community Mental Health Team leader gave evidence that it is not usual practice to place someone in an uninspected home, though does happen. She also told the inquest that it is difficult to place those with a complex presentation including Asperger’s in the Somerset area. Consultant Psychiatrist Dr Mynors-Wallis gave evidence suggesting this extended to a national issue. 

Amanda Richards, Robin’s mother said: "As a family we are elated and overwhelmed by the powerful conclusion reached by the jury. We are so happy that they agreed with all our concerns, including the issue of appropriate and person-centred risk assessment that involves family and the vital importance of communication with family and between professionals. In this case, Robin's suicide was not a bolt from the blue event, but accurately predicted by us, his family. This in itself is very shocking. It should never again be possible to lose a loved one in this way."

Victoria McNally, INQUEST caseworker for the family said: “The jury’s damning findings are a wholescale rejection of the systems that should have operated to keep Robin safe.  Robin’s case is one of an increasing number we are seeing involving failures around the assessment and provision of mental health care for people with Asperger’s and Autism.  We fear that the needs of this particular group have slipped outside the Government’s focus in its work around mental health.  We call now for engagement with families like Robin’s to inform Government of the changes needed to better protect the safety and mental health of people living with these conditions.”

ENDS

NOTES TO EDITORS

For further information, please contact Lucy McKay on 020 7263 1111 or here. 

INQUEST has been working with the family of Robin Richards since his death.  The family is represented by INQUEST Lawyers Group members Clare Evans of McMillan Williams solicitors and Rachel Barrett of Cloisters Chambers.

• Interested Persons at the inquest included: Somerset Partnership NHS Foundation Trust, Somerset County Council, Tracscare Ltd (now known as accomplish.) and the CQC.
  
  
• Tracscare are a care provider for people with Autism, Learning Disabilities, Mental Health needs and Brain Injuries. In February 2018 they rebranded and are now called ‘accomplish.’ The CQC found that Tracscare’s safety, effectiveness and leadership require improvement (more info here). Since rebranding they are yet to be inspected.
  
  
• Just weeks after Robin’s death the CQC conducted an unannounced inspection of Highbridge Court. The report of this inspection rated the safety and leadership of the care home as inadequate, and all other aspects as requiring improvement. Special measures were imposed as the CQC identified that residents at the home remained at serious risk of harm.  You can read the report here.