Coroner’s Court jury notes failings over young man’s suicide

Last week, a case on which our Medical Negligence team began advising last year, concerning the tragic case of a 25-year-old man with a history of mental health crises, concluded with a jury inquest at Avon Coroner’s Court in Bristol, which recorded a conclusion of ‘suicide, when the balance of his mind was disturbed’. It was uncertain whether the act was planned or impulsive.

In their Record of Inquest, the jury said they felt that the overall response to Dominic Vickars’ schizophrenia and depressive symptoms had been insufficient. They added that action following assessment of a high suicide risk was inadequate, whilst levels of observation within his mental health intensive care unit had been unclear.

The Court heard that Dominic died of hypoxic brain injury due to asphyxia on 6 June 2019 at Southmead Hospital in Bristol, following emergency transfer a few days earlier from Cygnet Hospital Kewstoke at Weston-super-Mare. Fun-loving, adventurous and creative as a child, he developed mental illness about three years ago.

After a gap year travelling, Dominic commenced studies at a university in Prague. By mid-2017 his mental health had deteriorated and he returned to his mother Merryn Sorrell’s home in South Devon. She sought help from local mental health services but was referred to the NHS 111 service.

After Merryn’s fraught call to 111, Dominic attended Torbay Hospital A&E. After a six-hour wait, he was seen and later given a Mental Health Act (MHA) assessment and detained under Section 2 at a hospital in North Devon, 50 miles away from supportive family members.

Dominic was diagnosed with schizophrenia and agreed to antipsychotic medication. He stayed on as a voluntary patient but within days returned to Merryn’s home. He soon stopped taking his medication, avoided contact with a crisis team and denied he had a problem.

Not until January 2019 was a first consultation with a psychiatrist arranged. A low dose of antipsychotic brought visible improvement, but an overdose six weeks later took Dominic back to Torbay Hospital A&E. He was checked for physical injury but not seen by mental health staff.

Dominic returned to the South Devon flat organised by family but was soon back at Torbay Hospital after swallowing household bleach. A voluntary inpatient mental health bed was sought. A Devon hospital declined but a bed was offered at Cygnet Hospital Taunton. He was admitted on 30 March.

After Dominic’s behaviour became bizarre and aggressive, he was again detained under Section 2 of the MHA on 8 April. Days later he was moved to Cygnet Hospital Kewstoke for psychiatric intensive care. This was a two-hour journey for visitors from South Devon.

Later in April, Dominic collapsed. After this, the doctor agreed to discontinue the second of his antipsychotic medications. Early May saw some improvement. Plans to move him to a less secure unit nearer home were discussed, but paused over renewed issues with his medication.

Mid-May brought deterioration in Dominic’s mental state. Suicide risk was assessed as moderate in a controlled environment and hopes of a return to Devon were revived. However, his low mood worsened at Kewstoke and his nighttime medication was altered.

On 31 May the family was told that Dominic had been transferred to Southmead Hospital after trying to take his own life. Despite successful cardiopulmonary resuscitation, artificial ventilation and life support, Dominic never regained consciousness and life support was withdrawn on 6 June.

“As the jury’s conclusions indicate, the circumstances of this case reflect inadequacies and missed opportunities at various stages of Dominic’s difficult two years following his return from studying in Prague,” said our expert Medical Negligence Solicitor Craig Knightley, who was acting for Merryn Sorrell.

“My client feels that her son’s death was totally avoidable and believes that placement in Cygnet’s mental health units in Somerset didn’t provide the safe, protective, therapeutic environment he had been promised when he agreed to go initially to Cygnet Hospital Taunton. The jury noted that all factors had not been adequately combined to inform an appropriate care management plan.

“His admission to Cygnet Hospital Taunton and what ensued significantly increased the risk of him taking his own life. This occurred in the Kewstoke psychiatric intensive care unit, where he had been placed against his wishes, despite the family raising numerous concerns about his mental state and suicidal thoughts.

“One of several disturbing features of Dominic Vickars’ experience was the widely found problem of patients being placed in units many miles from home. This adds to their feeling of isolation, which is obviously made worse by the inability of family and friends to visit as often as they would wish.”