A new Preventing Future Deaths report has caused me some consternation, I’ll be honest. Issued by His Majesty’s Inner West London, the PFD notice follows the death of Roberto Bettello in September 2020 after he was detained under section 136 of the Mental Health Act 1983 and removed to an Emergency Department as a Place of Safety. The issues for the police are limited, it is the matters of concern which relates to Central and North West London Mental Health Trust (CNWL) which cause my consternation.
Prior to his detention by the police, Roberto presented to the urgent care centre of Hillingdon hospital and was referred to an addicted recovery service known as ARCH. There were also two GP referrals to ARCH and a further self-referral but he was not seen prior to his death. On the 13th and 14th September, he presented to four police officers which resulted in three MERLIN reports (IT submission to flag adults at risk) which were all on his psychiatric records by 15th September. Last seen by his family on the 14th September, Roberto was reported missing by the morning of the 15th September and he came to the attention of the police just after midnight on the 16th September in central London.
The officers felt he was extremely agitated, clenching his teeth and grinding them, the officers suspected he may be exhibiting signs of acute behavioural disturbance and at one point during the contact, he charged at the police officers and was pushed back and then restrained. Not immediately detained and handcuffed, he went of to exhibit further agitated behaviour so was detained under s136 MHA and handcuffed and then leg restraints were used. He was taken to St Mary’s Hospital by ambulance.
EMERGENCY DEPARTMENT
Roberto remained in ED with two police officers who liaised with mental health staff to identify a suitable Place of Safety for them. By 0320hrs on 16th September, ED felt he was fit to be moved on but the question remained of where he would be moved to. Meanwhile, he was referred for psychiatric liaison in ED at 0326hrs, because it was felt he was suffering an acute psychotic episode. The PFD notice is curious on the next point: it was psych liaison saw him at 0355hrs and “referred to the psychiatrist for a MHA assessment” at 0434hrs – this is curious because assessment by a doctor and an Approved Mental Health Professional due to being detained under s136. It doesn’t matter what psych liaison nurses think is required on this point, DR-AMHP assessment is mandatory by law for every held under that power. Anyway, a decision was taken to defer the assessment until after 0900hrs.
At this point, it appears the police and NHS only knew Roberto’s first name. The coroner expressed concern that efforts to establish his full identity were not satisfactory and assumptions were made about his identity, the details of which are not fully explained but appear to be around his potential date of birth. There is further confusion about the availability of a mental health unit Place of Safety in Hillingdon and he was not transferred there. I remain a little confused because detail is in the PFD is not always on point, but I think someone called Roberto had been recently discharged from hospital and it was perhaps felt they didn’t need to be seen because of how recently they’d just left but what is clear is that Roberto was not the one with the police at St Mary’s ED.
Around 0600hrs, Robert became agitated again and stood on the bed in the ED cubicle. He then moved on to the window sill and kicked the window, breaking the glass. he then exited the window, falling 25-feet to the canal path below. NHS staff and the two police officers attended him on the canal path and he had sustained various injuries, including significant loss of blood and two collapsed lungs. He was rushed to surgery and various interventions were attempted but ultimately, he lost his life.
CAUSES AND CONTRIBUTORS
The coroner determined various factors were possible causes or contributors –
- The cubicle in which he was held was inadequate – not designed for mental health patients, the bed was near a window at the same level and no measure in place to prevent patients breaking the window or exiting it.
- Insufficient communication by everyone – MH trust and police, ED and psych liaison; psych liaison and police; Hillingdon MH bed manager and MH staff and the Hillingdon bed manager and the police.
- Information management system were inadequate
- The absence of a registered mental health nurse to care for Roberto whilst detained who the coroner believes would have had the skills and training to better monitor changes in behaviour and increases in agitation.
- Confusion about Roberto’s full identify
- The lack of available s136 suites.
The jury concluded Roberto –
“was experiencing acute psychotic episode. He was detained under s136 of the Mental Health ACt. He broke the window of his hospital cubicle with his feet and exited the window falling to the canal path below. In doing so, he suffered multiple injuries including cuts from the broken glass the divided his axillary vein and artery and led to his death.”
INVESTIGATION AT INQUEST
There was criticism of what the police officers were asked to do, including that
- They were told to ring around to find a Place of Safety which could take Roberto, despite policy stating this responsibility sat with NHS staff.
- It turns out the Place of Safety at Hillingdon was empty and should have been available for use, but had not been declared available when it should have been.
- Confusion that Roberto’s full identify was not established despite the court feeling it would have been easy to do so, if information had been properly exchanged.
- Lack of awareness by managers of the policy that should have operated.
The most concerning aspect of the coroners investigation however, relates to the Coroner’s efforts to prepare for the inquest. It’s easiest to just quote the PFD, because it speaks for itself —
“The court had experienced immense difficult in getting evidence from CNWL in relation to the Hillingdon issues despite repeated requests, such that evidence was not clarified until the last day of evidence and after further directions had been given live in court. This was in my view a failure of the duty of candour by CNWL.”
“It was also clear to the court and jury that the evidence of SPA witnesses was at times not credible despite recording of the calls they made and transcripts of these calls being used as part of the evidence.”
“There were obvious errors made by SPA staff in relation to how they search their computer systems to identify individuals.”
“Together these matters meant that a section 136 suite was not made available to Roberto that should have been and it was possible that this contributed to his death.”
“The psychiatric liaison nurse did not share the assessment and differential diagnosis made by the A&E doctors with the psychiatric registrar. This was especially poignant in this case as it became clear that Roberto was not intoxicated at the time and was psychotic, rather than his symptoms being due to acute intoxication with drugs and/or alcohol as was assumed by the psychiatric liaison nurse and passed to the psychiatric registrar. The A&E doctor had diagnosed Roberto correctly some hours before his death and medically discharged Roberto. This was recognised by the psychiatric registrar, who is now a consultant, as a point of learning for her and psychiatric liaison.”
”Evidence from the psychiatric doctor was that there are severe resource shortages in the area in which she now works with up to 50% of psychiatric nursing staff posts being vacant.”
MATTERS OF CONCERN
- CNWL failed in its duty of candour in relation to provision of evidence in this case.
- The evidence given by the SPA witnesses was at times not credible.
- Psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors, for example those who see such patients repeatedly in ED as in this case.
I might as well just stop typing there. Nothing can be added to that, realistically.
There is more ABD content on my specific ABD resources page.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2024
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
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