A series of failings by 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 self-harmed on 1 July last year during a psychotic episode two days after being refused a crisis admission by Norfolk and Suffolk foundation trust (NSFT) despite warnings from his family and a trust psychiatrist, Norfolk coroner’s court heard.
Sidle threw himself from a taxi three days after he became acutely psychotic and told his family that “aliens were coming” and that he had “three days left to live”.
NSFT’s 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 revealed by the evidence. He died from head injuries in hospital on 4 July.
Following the verdict, Sidle’s family backed calls for a public inquiry into a series of failures at the trust, including its inability to account for 8,440 “unexpected” deaths among its patients or those it recently cared for between 2019 and 2022.
The last psychiatrist who assessed Sidle, Dr Vassiliki Papachronopoulou, also warned a trust manager she was “extremely concerned” about the trust’s refusal to admit Sidle. But this warning also went unheeded, the inquest heard.
On 29 June, Sidle was refused a hospital bed based on the assessment of a newly qualified mental health nurse, acting without supervision for the first time, the inquest heard.
The court was read a transcript of a call on Thursday 29 July between Katie Sidle, who specialises in conditions that often present as psychosis, and the nurse, in which she relayed that her brother was “acutely psychotic”, had a history of masking his symptoms, and had told her that morning he now only “two days left to live”.
She told the nurse: “Sunday [1 July] will be day zero, I’ve no idea what he will do but I’m worried it will be pretty catastrophic.”
But the nurse insisted Sidle was “not psychotic” and refused to reassess him for a crisis mental health bed. Summing up the inquest, Lake noted that the assessment was carried without input from others in mental health team and without Sidle’s notes being read.
Lake said: “The assessment was inadequate and was a further missed opportunity to provide appropriate inpatient care to Christopher which more than minimally contributed to his death.”
Lake also highlighted other “missed opportunities” including emails between teams not being acted upon and a previous “inadequate” assessment of Sidle on 19 May by another nurse who refused to provide hospital care. During this assessment “psychotic markers were underestimated and/or missed”, Lake said.
On the morning of the fatal incident, Katie Sidle again tried to find a hospital bed for her brother. She was told 28 patients were awaiting an acute mental health bed at the time, her evidence submitted to the inquest said.
Lake confirmed that she would be publishing two prevention of future deaths reports in the coming weeks. One will address the trusts failings. Lake said: “Training clearly needs to go further. I’m also not convinced that action has been taken to ensure that all emails are picked up promptly and passed to the relevant person.”
The other report will be sent to health secretary expressing Lake’s “concerns” about the lack of mental health beds.
A family statement, issued through their lawyers, Ashtons Legal, said: “We do not hold the individual clinicians involved in Chris’s care personally accountable for his death – from our perspective, they too are victims of a failing and dangerous system. We know that Chris would echo this opinion.
“Chris’s death was entirely avoidable. We expect the trust to take the coroner’s findings seriously. It must follow through with its action plan to address the failings that have been identified.
“Until this trust’s systemic, longstanding failures are remedied – which it has failed to do despite having been in and out of special measures for nearly a decade – there will be further avoidable deaths and families left wondering why previous warnings were not heeded.”
“There have been calls for a public inquiry into the quality and delivery of mental health services carried out by NSFT, and we as a family support those calls.”
Cath Byford, the NSFT deputy chief executive, said: “We have taken action to improve as a trust following Christopher’s sad death. This includes amending our crisis triage tool to collect more detailed information and improved staff training. We have also implemented a ‘Think Family’quality improvement project to capture family and carer knowledge in relation to patient history. This will help us to engage and work with service users, their families, and carers to make the best care decisions to support our patients and identify when further support or intervention is needed.”
“We will act on all concerns raised by the coroner and work to ensure further learning and improvements are embedded.”
In the UK, the charity Mind is available on 0300 123 3393. In the US, call or text Mental Health America at 988 or chat 988lifeline.org. In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978
