Prevention of Future Deaths report – Benjamin Stroud (8 February 2022)

Summary

Benjamin Lee Stroud died on the 19 March 2021 at home. He lived alone but had a partner who saw him regularly. He had a previous medical history of recreational drugs, including steroids and cannabis; he was recently diagnosed as insulin dependent diabetic and had undergone a kidney transplant. He fell and injured his back at work, and developed a dependence on pain medication, some of which were purchased on the internet. His mental health issues increased as a result of his psychical health problems.

A post mortem was undertaken and the cause of death was multiple drug toxicity.

Content

Mr Stroud had been admitted from A&E under section 2 of the Mental Health Act between the 16 and 24 January 2021, to the Lindon Centre. He was then released under the ambit of The Gables and had been seen by a psychiatrist whilst under section 2. This appeared from the evidence to be the only time he was seen by such a person.

On the 22 February 2021, he took an overdose of insulin; however, as his partner is a nurse, he didn’t attend hospital as she knew what to do. A PSIIR report and action plan was completed. Mr Stroud’s partner gave evidence, and it was clear from her account that she had been begging the care coordinator for Mr Stroud to have an appointment with the psychiatrist, which did not occur. From the evidence of EPUT, it was clear that Mr Stroud’s care coordinator did not make any referral to the MDT, despite his escalating psychosis. It was also clear from the evidence that none of the conversations with Mr Stroud’s care coordinator were recorded.

The action plan stated that one of the actions implemented since Mr Stroud’s death was that ‘all communications with the client should be recorded’.

Matters of concern:

That in all cases must go before the MDT, the evidence in this inquest made it clear that had Mr Stroud’s case been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death.

On the evidence from EPUT and the PSIIR it was clear that the care coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rational for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a care coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring.