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Inquest into overdose death at leading London psychiatric hospital finds systematic failures by staff
6 March 2015
A jury at the inquest into the death of Derek Richards, a 39-year-old father of two, from Croydon who died whilst under section at Bethlem Royal Hospital, a psychiatric hospital in Beckenham, South London, has found that ‘systematic failures in training and procedure’ by medical staff contributed to his death.
The inquest into Mr Richards’ death began on 2 March and concluded on 5 March 2015. It was held in the South London Coroner’s Court sitting at Bromley Civic Centre and overseen by Senior Coroner, Selena Lynch. The jury found that the death of Derek Richards, who died on 19th May 2012 of a methadone and diazepam overdose, followed multiple failures by the hospital including inadequate training, lack of communication, poor record keeping and incorrect prescribing of medication.
Mr Richards had a long history of mental health problems and substance abuse. In April 2012 he was arrested and, following a mental health assessment, was sectioned and transferred to the psychiatric intensive care unit at Bethlem Royal Hospital where he remained until his death.
Whilst in hospital he was prescribed methadone in order to manage his drug dependency. In the run up to his death, Mr Richards had asked a number of times for the dosage to be reduced. Mr Richards refused his methadone dose during three separate periods during his admission, two lasting two days and one, five days. Further on one occasion the dosage was lowered as the ward had run out of the drug. The refused doses were not taken into consideration, nor was the fact the deceased would have lost tolerance for the drug, and the range of other medication he was also being prescribed at the time. As a result the dosages were not adjusted accordingly.
The inquest heard evidence from Toxicologist, Dr Paterson, who confirmed that the levels of methadone and diazepam found in the deceased’s blood after his death were consistent with the levels prescribed and administered to him by healthcare staff. Dr Paton, a Pharmacologist explained that there needed to be caution when using Methadone and Diazepam together due to their similar effects. She also expressed concern that the deceased was still being prescribed methadone when he had shown no withdrawal symptoms during the periods he was not taking the drug.
The jury determined that Mr Richards’ cause of death was methadone and diazepam toxicity as a result of drugs prescribed and administered at Bethlem Royal Hospital. They concluded a verdict of accidental death due to systematic failures in training and procedure, specifically:
• Inadequate training with regard to: correlation of drug charts, the risks associated with methadone, and the risks associated with methadone and diazepam in combination
• Inadequate training of nurses about the need to alert senior staff to refusals of medication
• Lack of communication with regard to refused doses between nursing staff, doctors and the pharmacy
• Failure to record accurate observations on drug sheets and electronic records
• Failure to have drugs records available at all times
• The fact that prescribed methadone and diazepam had toxic effects because doses of methadone had been missed leading to reduced tolerance. The risk of methadone toxicity and methadone and diazepam in combination was not adequately recognised or managed and this contributed significantly to the death of Mr Richards
• Failure to retitrate (i.e. adjust the prescription) following five days of refusal of methadone as a result of the medical team not referencing all available documentation
• Nursing staff incorrectly entering into the records that Mr Richards was compliant with medication despite his refusal of methadone.
Mr Richards’ family was represented by Clair Hilder of Hodge Jones & Allen, and Kirsten Sjovoll of Matrix Chambers.
Clair Hilder says: “When Mr Richards went to Bethlem Royal Hospital his family thought that it was the best place for him and that he would be safe there. In fact, as the jury made clear, the hospital did not have adequate training in place for staff, nor were there sufficient systems in place to safeguard those who were prescribed powerful medication. The multiple failures by medical staff ultimately contributed to a drugs overdose, resulting in Mr Richards’ death.
Last month the Equality and Human Rights Commission reported they had found that repeated basic errors, failures to learn lessons and a lack of rigorous systems and procedures had contributed to the non-natural deaths of hundreds of people with mental health conditions in detention between 2010 and 2013. Mr Richards’ death is another tragic example, and highlights that more needs to be done to avoid mistakes in relation to psychiatric patient’s physical health.”
Mr Richards’ aunt Ms Linda Simmons, said; “It is now almost three years since Derek’s death and I am pleased that the failings which occurred at the hospital are now out in the open. I hope that this will help ensure that this does not happen to anyone else in the future. Whilst many changes have been made I am still concerned that the hospital’s drug prescription and administration charts are kept separately from patient’s medical records, so that missed doses may not always be clear. I also found it shocking that there appeared to be no one to show the Ambulance Service where to find Derek’s ward which led to one paramedic driving around the hospital site for approximately 7 minutes before finding where she had to be.”
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Notes to editors:
Hodge Jones & Allen LLP was founded in 1977 in Camden and has 200 staff based in Euston NW1. The firm practices personal injury, clinical negligence, civil liberties, family law, wills and probate, housing, dispute resolution, criminal defence and serious fraud.
The Civil Liberties team at Hodge Jones & Allen is one of the UK’s foremost teams in bringing actions against the police and state authorities for deaths in custody. The firm’s solicitors work closely with INQUEST, which works for truth, justice and accountability for families, and campaigns for policy change at the highest level.