When a mum went into her son’s supported home after he died, it was littered with rancid food containers and unused prescription drugs.
Linda Durrant gave the inquest in Bury St Edmunds on Monday a list of what she saw as the ways the support company Julian Support and the Norfolk and Suffolk Foundation Trust, which runs mental health services, had failed her schizophrenic son Daniel Chapman, who was brought up in Sudbury and went to Sudbury Upper School.
They included not ensuring he took medication, making numerous changes to his community psychiatric nurses so he had difficulty engaging, failing to comply with a directive to involve her in care and pressuring him to move from his supported home in Jankyns Place, Bury.
Ms Durrant, from Sudbury, added: “If Julian Support and Norfolk and Suffolk mental health trust had been doing their jobs properly, my son might not have died that day.”
Dan, 33, died on October 31, 2014, at a friend’s home in Ridley Road, Bury, after taking the then legal high Etizolan at 22 times the therapeutic dose. The inquest heard the now illegal drug was known to have an adverse reaction with the schizophrenia drug he was on, Cloriazil.
Ms Durrant said her son moved into Jankyns Place after a spell in hospital in 2003 and had done well there. It then had staff on site 24 hours.
In January 2009 an attempt was made to take him off Cloriazil but he was admitted to hospital again. She said she and Dan then agreed an advance directive that he signed to say she should be involved in his care.
She said the contract to run Jankyns Place was then put out to tender with the support side going to Julian Support, staff no longer slept there and support was reduced.
After Dan’s death she went to his home. She said: “I was horrified at the state I found the flat in. The lounge was littered with rancid food containers.”
She found many Cloriazil containers with the day-stamped doses untaken.
Karl Doyle said he had visited Dan’s home on the morning before he died and found him and a friend Colin Curry ‘high on drugs’ and waiting for the post to bring more. He invited them to his home and when he got there they were already there and high.
Mr Doyle said Dan slept on an armchair and at 9am the next day was snoring. But shortly after 11am he and a friend realised Dan was no longer breathing.
Claire Mawer, representing Ms Durrant, asked what Dan’s relationship with the care providers was.
Mr Doyle replied: “He had as good as zero help from the people at that place.”
Toxicologist Dr Rebecca Andrews said they had found Etizolan and another legal high, in Dan’s blood, with prescription drugs. She said Etizolan caused respiratory depression which was known to be made worse by Cloriazil.
Pathologist Dr Iwona Kaminska explained how the drugs inhibited the brain’s receptors that pick up levels of carbon dioxide in the blood. She added: “Snoring is a symptom of depression of the respiratory system because you can’t inhale properly.”
Coroner Dr Peter Dean asked Dr Albert Michael, a consultant psychiatrist at Wedgwood House, Bury, if Dan was aware using drugs affected his illness.
Dr Michael said Dan craved company and mixed with drug takers. He added: “Drugs make the symptoms worse and I think Dan was aware of it, but he would have to balance between the symptoms being under control and him being alone or having symptoms and the company.”
Dr Michael said patients failing to take medication was normal, as with anyone on medicines. He added: “A person involved in Dan’s care would have to strike a balance between inciting a relapse because of over involvement and a relapse because he was not taking medication.”
Dr Dean asked about the failure to include Ms Durrant in care decisions.
Dr Michael said that even if a patient had signed an advance directive, if they requested relatives were not contacted and the hospital did so, a complaint against the hospital could be upheld.
He added: “The law doesn’t allow carers to have the medical information and the law doesn’t protect staff who keep carers informed, even when it is in the best interests of the patient.”
Pip Coker, chief executive of Julian Support, said they did a survey among users in Suffolk and 56 of the 88 people they sent questionnaires to responded, of whom 54 rated the service they received as ‘good to excellent’.
Sam Pickering, a recovery coordinator with Julian Support, said Dan, who he described as ‘a likeable person’ had told him he wanted to end the advance directive and his manager had told him to get it in writing.
Dr Dean asked if it was felt there was a need to inform Ms Durrant.
Mr Pickering said at the time he felt he was bound by Dan’s wish not to contact her.
Dr Dean asked: “Wouldn’t it be reasonable to ask if he minded her being informed?”
Mr Pickering replied: “Yes”.
Dr Dean added: “If she doesn’t know the agreement has been terminated, she’s going to think no news is good news?”
Mr Pickering replied: “Yes”.
Mr Pickering said the company had since changed policies on advance directives, including regularly reviewing the consents for them.
He said that Dan had told him he ‘needed to grow up and take responsibility for himself’.
Dr Dean asked if there was pressure on Dan to move and Mr Pickering said: “There’s no pressure to move but that’s the desire of the service. It’s all about working with people to develop independence skills to move into independent accommodation, so that was discussed.”
He said Dan had started working on packing so it would be less pressure than packing everything up close to a move.
He said he had talked about to Dan about how drug use and alcohol would have a negative effect on his treatment and said Dan had experienced the impact when supporting a friend who had ended up in hospital because of drugs and alcohol.
Mr Pickering said that he became concerned Dan might be using drugs after complaints from his neighbours about a known drugs dealer visiting and he had emailed the care team on October 8 suggesting Ms Durrant be told.
He explained how he had talked to Dan about personal hygiene and housework and had helped him budget for a cleaner.
Rachel Omori, who was then Julian Support’s Suffolk head of operations and development, said in a statement to the inquest that moving had first been discussed with Dan in November 2013 and he had registered with the social housing search website Homelink, to find a new home.
“He engaged with support workers, often excitedly, to look for new homes,” she said.
Dr Dean asked her how difficult it was to give information to family if the client did not want it.
She replied: “The primary person you work with in the service is the user – you’re concerned about the family relationship, but that’s the person you take guidance from.”
She added that since Dan’s death and Ms Durrant’s complaint to Julian Support they had compiled a handbook for families and carers to set out the roles of the different agencies involved.
When clients’ care is reviewed,at least every three months, any consents to information being given or withheld are now reviewed. Staff had also been given more guidance on advance decisions and consents.
On moving Dan, she said that Julian Support offered primarily a recovery service where people would be encouraged to move on but there was ‘never any time limit on how long people can stay’. She added that a shortage of accommodation in Bury meant, even if someone said they were ready to move, it could take months.
John Clutton, Norfolk and Suffolk Foundation Trust’s integrated delivery manager, presented the trust’s serious incident report to the inquest.
The report said documentation on Dan’s case was of a good standard but included information drawn in from older reports without being updated. Though it was still valid, it included references to old organisations and people no longer in post.
It said Ms Durrant’s complaint was partially upheld in that ward staff did not make themselves aware of the advance directive and were only responding to Dan’s current wishes.
Mr Clutton explained how their old computer programmes would have only stated that there was an advance directive with a chronological list of documents, where the new one includes the wording of a consent at that point.
In addition, the old programme automatically pulled in information from older records putting the onus on the person to ensure it was updated. He said the new system started with a blank document so if older information was still relevant it had to be manually copied across and the system was ‘much more explicit about current issues and historic issues’.
He explained that advance directives and patient wishes are made while they have the capacity to do so but they can change it as long as they have the capacity.
Dominic Ruck-Keen, representing the trust, asked: “Until the patient has lost capacity, any statement about who he wanted involved in his care wasn’t relevant. It just needed to be kept up to date until needed?”
Mr Clutton replied: “Yes”.
In summing up at the end of the five-day inquest Dr Dean said: “This has been an unusual inquest in that we have gone into a considerable amount of detail in trying to establish what the circumstances of the death and what might be described as the scene in which it occurred.”
He said Dan had had ‘multi layered problems’ and he said there were areas where those close to him could see potential difficulties. He said Dan ‘clearly had the capacity’ to make the decision to exclude his mother from his care. He praised the support the family gave Dan.
Dr Dean added that if legal highs had not been made illegal in May he would have called for action because of the ‘Russian roulette’ risk Dan’s death had illustrated. He said Dan may have taken many tablets or just been unlucky in taking a couple that were higher strength than expected.
Dr Dean recorded that Dan had died of multi-drug abuse.
His narrative verdict said: “He died as a tragic but involuntary consequence of taking drugs referred to at the time as legal highs.
“Dan was also taking medication for a long standing mental health condition which may have interacted.”
After the inquest Linda Durrant vowed to fight for care in the community providers to have the same Care Quality Commission inspections as care homes.
She said: “Julian Support is an unregulated care provider that is not inspected. At least NSFT has the CQC looking at whether they’re adequate.”
She said the coroner was right to say that because she was not told Dan had withdrawn consent she thought ‘no news was good news’.
“If they had told me I would have had the opportunity to have done something, “ she said. “It was four months after Dan’s death that I found out what had happened,”
She is angry at the repeated changes of Dan’s community psychiatric nurses and that none asked her why he failed to engage. Dan was scared of strangers so the changes would have been hard for him.
Julian Support’s chief executive Pip Coker said after the inquest: “We did a thorough investigation as soon as Ms Durrant raised her concerns.
“If anything needed addressing, we’ve already done it. That’s one reason wyh we’ve developed this family, friends and carers handbook.”
She said the case had shown that while staff in mental healthcare understood t consents and how the system worked, it was confusing to those new to it.