Inquest finds discharge planning at NHS trust contributed to autistic man’s death

An inquest has found that an NHS trust mental health unit’s discharge planning, alongside a decision not to recall a young autistic man with mental ill health, contributed to his death.

Tom Creffield was 24 years old when he died on 6th February 2020 at his flat in Redcar, Teeside. At the time he was on a short period of leave from Lustrum Vale mental health unit in Stockton-On-Tees, run by Tees, Esk and Wear Valleys NHS Trust (TEWV), where he was receiving treatment.

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TEWV has been criticised for a high number of patient deaths, with research uncovering hundreds of deaths between April 2017 and March 2020.

In their evidence to the inquest, Tom’s family described him as beautiful, imaginative, and clever. Tom had diagnoses of paranoid schizophrenia and autism. He been in and out of inpatient care since he was 18, most recently for over two years.

At the time of his death Tom’s treating team were working towards discharge back into the community. Tom had a long history of self-harm and suicidal thoughts. These remained chronic symptoms of his presentation, which were still a concern at the time of his death.

The jury found that Tom did not intend to take his own life on 6th February 2020. They also found that the trust’s plan to discharge Tom to live alone in private rented accommodation was not in his best interests and that this probably contributed more than minimally to his death.

The jury also found that respective decisions to allow him on a seven-day period of leave on 3rd February, to allow him unrestricted access to knives, and not to subsequently recall him back from leave were not in his best interests and probably contributed more than minimally to his death.

Tom’s mother Claire Creffield said: ‘Senior members of Tom’s care team let him down badly at a time when he was desperately vulnerable. The lessons learned from his death must not simply result in the introduction of yet more paperwork. There needs to be a genuine improvement in clinicians’ ability to hear their patients’ voices, to explore with patients what their needs are, and to meet those needs effectively.’

Gemma Vine of Ison Harrison Solicitors said: ‘The evidence that we heard at this inquest demonstrated that Tom’s discharge was at best haphazard and at worst shambolic. Clinicians were unable to confirm who had responsibility in making key decisions and enquiries regarding what type of accommodation would have been in Tom’s best interest upon discharge.

‘It was very clear that there was poor record keeping and key decisions regarding assessments as to what would be in Tom’s best interest, particularly relating to accommodation and the support that was required on discharge was at no point recorded in the notes.

‘Furthermore, a lack of record keeping and discussions between the multidisciplinary team meant that key concerns about Tom’s presentation whilst on leave were not considered. This resulted in a missed opportunity to recall Tom back to the ward, or at least make a full assessment of his current mental health presentation before his death. Had this happened we fully believe that Tom may not have died that evening.’

Lucy McKay, spokesperson for INQUEST, said: ‘Tom was receiving care under a mental health Trust that has been widely criticised for its part in many other preventable deaths. He is yet another a young man with autism and mental ill health who has been failed by the NHS. Urgent action must be taken locally and nationally to address the issues identified and ensure this Trust can provide safe care in future.’

Image: Peter Burdon

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