You may remember from late last year, I’ve made a large noise about the inquest in to the death of David Stacey in Leicester. David died in late 2017 and the inquest just before Christmas last year, concluded that his accidental death in road collision had been contributed to by the neglect of NHS services.  In particular, it was alleged that non-compliance with s140 MHA and there being no beds available for urgent admissions, was such a problem that it required a Preventing Future Deaths report to the Secretary of State for Health as well as to the relevant Leicestershire mental health services and clinical commissioning groups.

This post is just a short addition because yesterday Leicester City Council published a Safeguarding Adults Review report after a learning event held in the city last year. The report is now a public document and it speaks for itself.  However, I want to make three quick points in respect of it and leave you to your conclusions.

  • You’ll notice that it is dated ‘September 2018’, having been written by an independent Approved Mental Health Professional after the learning event mid-year.
  • You’ll remember from the previous post that the inquest in this case took place in December 2018 and the verdict produced a week or so before Christmas.
  • I’m not aware of what the report author knows of the events at the Coroner’s court, if any. It goes unmentioned in the report, so my best guess is ‘none’ – happy to be corrected.

Having now read the fully published SAR (a public document) and having knowledge of the Coroner’s (public) proceedings, I feel it’s both fair and very necessary to say this:

The SAR report, whilst important for lots of reasons, presents a versions of events after the incident which differ from some of the things which were found by the Coroner or accepted by the parties involved once they reached the witness box of the court. I’m going to deliberately infuriate those who may be interesting in knowing detail, because I’m not listing examples of the kind of things I’m referring to.  Let’s just say that some claims reflected in the SAR changed by the time they reached the Coroner’s court.  That is not the fault of the report author or the city council who oversaw the SAR process, it just the inevitable potential of multiple reviews seeking to achieve different things.

But as the published legacy from this tragic case is the SAR report, not exhaustive coverage of Coroner’s proceedings and because I still maintain this type of thing could have gone badly awry in most parts of the country, it strikes me as important to ensure that lessons learned are not solely taken from the coverage in the SAR, which was completed before the inquest.

Accept nothing, Believe no-one, Check everything, Document it ALL and remember:
xpertise rarely stays in lane, so refer back to the start and go again.

Take care out there, folks – frontline cops were blamed in this case for contributing to a death by professionals who got the law wrong in a courtroom.

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, 2019

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 – http://www.legislation.gov.uk