Family's anger at mental health trust's response to death of Henry, 21
PUBLISHED: 18:24 08 April 2019 | UPDATED: 10:01 09 April 2019
The family of a 21-year-old Ipswich fashion student have blasted a mental health trust's response to a report aimed at preventing similar deaths.
Pippa Travis-Williams and Stuart Curtis, the parents of Henry Curtis-Williams who died by suicide in 2016, said they are “extremely displeased” with the Norfolk and Suffolk Foundation Trust (NSFT)’s response to a coroner’s report recommending it takes action to prevent future deaths like their son’s.
They are currently pursuing legal action against the trust, and claim Henry’s “lack of care” was nothing other than a “catalogue of fatal errors” made by NSFT.
“The family are extremely displeased with the NSFT response to the prevention of future deaths report made by Antek Lejk, previous chief executive,” they said.
“It was nothing other than a cleverly worded response of no substance whatsoever.
“The trust are specialists at making meaningless responses in times of crisis.”
What happened to Henry?
Dr Sean Cummings, assistant coroner for west London, concluded that fashion photography student Henry died by suicide in 2016.
On May 11 of that year, he was found by police near the Orwell Bridge despite telling family he was heading back to university in London.
He was taken to the Woodlands unit in Ipswich before being transferred to Southgate Ward in west Suffolk.
He was diagnosed as suffering from an adjustment disorder, and was considered a low suicide risk.
However, he was discharged the next day without a consultant review, an inquest into his death heard – by, the family claims, a junior doctor in his first year of training.
From there, Henry travelled to London where he was assessed by his GP and referred to the local crisis team for a response within 24 hours.
The 21-year-old was found hanged in Acton Cemetery on May 17, 2016. His family say they were not told about his severe depressive disorder, or his admission to hospital, until several weeks after his death.
Following the inquest, Mr Cummings wrote to the NSFT outlining three main concerns – a lack of recording contemporaneous notes, particularly when logging presence or absence of suicidal ideation; an acceptance that patients could be discharged by very junior doctors; and very informal communication between staff members on inpatient wards, without records being kept.
What was the NSFT’s response to the coroner’s report?
Written by Mr Lejk, the NSFT’s response suggests the trust has:
• Used Henry’s case in the provision of learning via its patient safety newsletter, with regards to recording contemporaneous notes
• Started a programme of work to “examine the barriers to using ‘clinical curiosity’ and develop the skills and frameworks for staff to ensure this critical aspect of care (contemporaneous note taking) is constantly applied”
• Completed an audit to examine its current practice of discharging patients, with 96% of discharges in August and September 2018 having evidence of a senior doctor or consultant making the decision
• Issued an internal alert to all inpatient wards “directing reflection on the points where information is received from differing sources, e.g. service users, families and carers and whether there is a shared process or understanding of how to ensure that information is captured”. Feedback on this alert was being received at the time of Mr Lejk’s response, dated February 11, 2019.
The former chief executive left the trust just over a month later, and has since been replaced by Professor Jonathan Warren.
Of the NSFT’s response, Henry’s family said it is “no wonder” that the trust remains in special measures.
It was rated ‘inadequate’ for a third time during an inspection in November.
What happens next?
The family have launched a legal challenge via Ashtons Legal, and are confident they will reach a resolution.
But they claimed: “Of course, no resolution will ever put right the loss of our dear son Henry, who should still be alive today, was it not for the decisions and actions made by the trust prior to Henry’s death.
“The family are united in their belief that Henry’s death was preventable, had they been informed of his acute psychiatric illness, and that Henry’s inappropriate, premature discharge by a junior doctor in his first year of training at Southgate Ward should never have taken place.
“The lack of care was nothing other than a catalogue of fatal errors all made by NSFT, resulting in Henry’s tragic suicide in May 2016.”
What did the NSFT have to say about the family’s concerns?
The trust’s medical director, Dr Bohdan Solomka, has offered to meet the family to hear their concerns.
“NSFT has a wholehearted commitment to investigate and learn from the circumstances surrounding the loss of anyone who has been in the care of our services,” he said.
“Therefore, it is disappointing to hear that the family of Henry Curtis-Williams are not satisfied with our response to the coroner’s prevention of future deaths report.
“This is the first time that we’ve heard that the family are unhappy with it so we will contact them shortly and offer a meeting so that we can listen to their concerns.
He added: “Finally, if there is any support we can offer to Henry’s family or friends, we would once again extend this offer to them along with our condolences.”
• Need to talk? Call Samaritans on 116 123 24 hours a day.