A series of failings at a troubled NHS mental health trust contributed to the death of a former government climate change adviser, a coroner has found.
Christopher Sidle, 51, who had a history of psychosis, fatally injured himself on July 1 last year during a psychotic episode, two days after he was refused crisis admission by the Norfolk and Suffolk Foundation Trust (NSFT) despite warnings from his family and a trusted psychiatrist, Norfolk District Court heard.
Sidle jumped out of a taxi three days after he became acutely psychotic, telling his family that “aliens were coming” and that he had “three days to live.”
The NSFT crisis team was repeatedly warned of this “countdown” by his sister, Dr Katie Sidle, a consultant neurologist, as she pleaded with staff to allow her brother to be admitted to hospital. But her concerns were ignored, the inquest heard.
Norfolk’s senior coroner Jacqueline Lake highlighted a series of “missed opportunities”, “inadequate assessments” and a lack of mental health beds in the weeks leading up to his death. Lake ruled out suicide and death by misadventure, as the state of Sidle’s mind was not evident from the evidence. He died in hospital on July 4 from head injuries.
Following the verdict, Sidle’s family backed calls for a public inquiry into a series of failures at the trust, including its failure to account for 8,440 “unexpected” deaths among patients or those it recently cared for between 2019 and 2022.
The last psychiatrist to assess Sidle, Dr Vassiliki Papachronopoulou, also warned a trust manager that she was “extremely concerned” about the trust’s refusal to admit Sidle. But this warning was also ignored, the inquest heard.
On June 29, Sidle was refused a hospital bed based on the assessment of a newly qualified mental health nurse, acting unsupervised for the first time, the inquest heard.
A transcript of a telephone conversation between Katie Sidle, who specializes in conditions that often masquerade as psychosis, and the nurse was read to the court on Thursday, July 29, in which she said her brother was ‘acutely psychotic’, had a history of masking his feelings. symptoms, and had told her that morning that he now had “only two days to live.”
She told the nurse: “Sunday (July 1) is day zero, I have no idea what he’s going to do but I’m afraid it will be quite catastrophic.”
But the nurse insisted Sidle was ‘not psychotic’ and refused to reassess him for a mental health crisis bed. In summary, Lake noted that the assessment was conducted without input from others on the mental health team and without reading Sidle’s notes.
Lake said: “The assessment was inadequate and was a missed opportunity to provide Christopher with appropriate inpatient care, which more than minimally contributed to his death.”
Lake also highlighted other “missed opportunities,” including inter-team emails that were not acted upon and a previous “inadequate” review of Sidle on May 19 by another nurse who declined to provide hospital care. During this review, “psychotic markers were underestimated and/or missed,” Lake said.
On the morning of the fatal incident, Katie Sidel tried again to find a hospital bed for her brother. She was told that 28 patients were awaiting an acute mental health bed at the time, according to her evidence submitted to the inquest.
Lake confirmed that she would release future death prevention reports on Sidle’s death in the coming weeks, which would address her “concerns” about the lack of beds and other “deficiencies” in Sidle’s care.
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“The training clearly needs to continue,” she said.
She added: “I am also not convinced that action has been taken to ensure that all emails are quickly picked up and passed on to the relevant person.”
A family statement, issued through their lawyers, Ashtons Legal, said: “We do not hold the individual doctors involved in Chris’s care personally responsible for his death – from our perspective they too are victims of a failed and dangerous system. We know Chris would agree with this view.
‘Chris’ death was completely avoidable. We expect the trust to take the coroner’s findings seriously. It should continue with its action plan to address the shortcomings identified.
“Until the systematic, long-term failures of this trust are addressed – which it has not been despite being in special measures for almost a decade – there will be further avoidable deaths and families will be left wondering why previous warnings were not heeded .”
“There have been calls for a public inquiry into the quality and delivery of mental health care, carried out by NSFT, and we as a family support these calls.”
Cath Byford, deputy director of NSFT, said: “We have taken action to improve our trust following Christopher’s sad death. This includes adapting our crisis triage tool to collect more detailed information and improving staff training. We also implemented a “Think Family” quality improvement project to capture family and caregiver knowledge of the patient’s history. This will help us to work with service users, their families and carers to make the best care decisions to support our patients and to determine when further support or intervention is needed.”
“We will take action on all concerns raised by the coroner and ensure that further learning and improvements are embedded.”