Mental heath trust responds to criticisms by coroner following inquest

Adam Smith’s body was discovered at Fiddlers Ferry on February 12, 2022, following a missing persons appeal that lasted for more than two weeks.

The conclusion of the inquest revealed that Adam, whilst experiencing a period of paranoia, had climbed into a storm drain that went below ground at the Fiddlers Ferry Power Station and drowned.

However, mistakes made by Mersey Care NHS Trust in the lead up to the 30-year-olds passing were criticised and determined as a contributing factor to his death.

During the inquest, which concluded at Cheshire Coroners Court last Friday (April 19), it was heard that Adam had dealt with issues relating to his mental health for years, including his diagnosis of borderline personality disorder. As well as issues concerning drug use and his attempts to self-medicate to cope with anxiety and paranoia episodes.

In the lead up to Adam’s death, he was suffering a mental health crisis, and was displaying signs of psychosis, when he was discharged on January 27, 2022, by a mental health team managed by Mersey Care NHS Foundation Trust.

And a community mental health team appointment that was scheduled to take place at his family home the following day was cancelled without warning by Mersey Care staff.

Despite the plea from Adam’s parents for the appointment to go ahead, they were told that this could only be carried out the following day and before the phone call had ended, Adam had left the house, never to be seen alive again by his family.

The inquest into Adam Smiths death concluded last week (Image: Supplied)
Recording a narrative conclusion, coroner Charlotte Keighley said that a plan to discharge him by Mersey Care NHS Foundation Trust was “not safe in practice”.

She found that the outcome of the Mental Health Act assessment undertaken before his discharge, would likely have been different, had it not been based on inaccurate information, and had the clinicians been aware of Adam’s history.

The Trust has now responded to these criticisms, stating that ‘immediately’ after the incident a ‘serious incident investigation’ was conducted and several changes were implemented following an internal review.

A Mersey Care NHS Foundation Trust spokesman said: “We are aware of the inquest into the death of one of our patients and would like to express our deepest sympathies to the friends, family and loved ones of the deceased at this difficult time.

“Mersey Care routinely reflects on all our practices as a learning organisation, but particularly after a tragic incident like this. Immediately after this incident we conducted a serious incident investigation and have implemented several recommendations from our internal review.”

Changes made to adjust the standards of care at Mersey Care included:

• Inviting and including family members to care reviews

• Ward managers to conduct a weekly audit of care reviews to ensure best practice is followed

• Further recruitment of ward staff, including health care assistants

• All patients to be offered an appointment within 48 hours of discharge from an inpatient setting.

“We’ll continue to monitor our standards of care throughout our services. As a Trust we remain committed to the delivery of high-quality care for all our patients, services users, carers and their families,” they added.