Mental health services criticised over death of Chalfont St Peter man Roy Morris

Carpenter Roy Morris, from Grove Hill, was sadly found dead five weeks after he went missing two years ago.

His body was found in woodland near the A40 in Gerrards Cross on June 30, 2019.

An inquest into his death heard that nine days before he went missing, Roy had been discharged from the Whiteleaf Centre, a mental health hospital in Aylesbury, where he had been admitted as an inpatient after an attempt to take his own life.

The inquest, at Beaconsfield Coroner's Court, was told of a “failure” to properly plan his discharge after he was admitted to the Whiteleaf Centre for 28 days, “which lacked a clear and comprehensive plan for his care and safety” when he returned home as a community mental health patient.

Lawyers for Mr Morris’s family  said: “A worsening in Roy’s mental health condition, which included paranoid features, was not recognised effectively by those many different staff who engaged with him following his discharge.”

His family also voiced concerns at the inquest around the care he had received as a mental health patient.

ALSO READ: Body of missing Roy Morris found in woodland

They said Roy, a talented guitarist who had no known history of anxiety, had been referred to community mental health services in April 2019 after he had developed severe work-related anxieties. He had also been experiencing severe sleeping difficulties since January.

The lawyers, at Leigh Day, said: “During an assessment on April 19 at The Valley Centre, in High Wycombe, Roy and his family were advised that he would need to attend the Adult Day Hospital on a voluntary basis when it reopened after the Bank Holiday weekend, on account of the severity of his condition.

“This service provides three hours of access to clinicians on weekday mornings. Hours later, he made an attempt to take his own life.

Roy Morris went missing in May 2019

“Roy was then admitted to the Whiteleaf Centre, where he spent the following 28 days as an inpatient.

“His family were initially relieved that he had been admitted, as they thought the Whiteleaf Centre would keep him safe and provide the treatment he needed.

“However, they said it soon became apparent that it was ‘very difficult to communicate meaningfully’ with staff.”

His family said they were “rarely” offered information about Roy’s care and they also did not “proactively approach” them to provide background information on Roy, nor collaborated with on his safety and care planning.

The inquest heard that bridging the gap between what the family knew of Roy’s worsening condition, and what the clinicians were able to glean from their interactions with him, “could have been crucial in keeping him safe”.

Independent expert witness, consultant psychiatrist Dr Mynors-Wallis, told the inquest that the management of Roy’s discharge from the Whiteleaf Centre, which lacked a care plan, was the “the most significant failure”. He also criticised the medication Roy was prescribed.

Senior Coroner for Buckinghamshire Crispin Butler said Roy Morris died as a result of suicide to which the following contributed “more than minimally”:

• The fact that there was no detailed written care plan for Roy on discharge into care in the community and the acute day hospital team
• The fact his care coordinator was only allocated shortly before discharge
• Roy’s family were not provided with the means to engage fully and candidly with the inpatient team.

Mr Butler also issued two prevention of future deaths recommendations:

• The application of care programme approach to patients such as Roy so that they have a detailed care plan
• The importance of the role of the care co-ordinator and the timely allocation of this person to inpatients shortly after admission so that they can work with the patient and family and mental health teams

Mr Morris’s daughter Ruby said: “We are devastated to hear that Roy’s death could have been prevented, but we are grateful to the court and the witnesses called for allowing us to have the concerns which we have held for almost two years validated.

“We hope that Oxford Health NHS Foundation Trust will take this grave opportunity to implement real, substantive actions that will prevent a tragedy like this from befalling another family.

“While it is clear that this trust’s practices need to change, it is apparent to me that Oxford Health’s specific failings in the care of my father reflect the larger picture of depleted mental health services nationally, with well-documented shortages of mental health clinicians and inpatient beds contributing to service inefficiencies, long waiting lists and ultimately, avoidable deaths.”

For confidential support in the UK, call the Samaritans on 116123, email jo@samaritans.org or visit a local Samaritans branch. See samaritans.org for more details.