Mental health trust ‘missed opportunities’ to keep Essex teen supported days before he died alone

Glenn was 19 when he died from an accidental overdose

His sister, Amanda Cook, is campaigning for a public inquiry into the county’s mental health services

A mental health Trust “missed opportunities” to keep an Essex teenager fully supported prior to his fatal overdose.

Glenn Holmes was 19 when he died alone from an accidental overdose at his temporary housing on July 7, 2012, just days before he was due to move into assisted living accommodation.

He had been a patient at the Lakes Mental Health Hospital in Colchester, operated by the North Essex Partnership Trust (NEP), on and off during the last few years of his life following a series of concerns for his health.

Following a complaint from Glenn’s sister, Amanda Cook, a report from the Parliamentary and Health Service Ombudsman (PHSO) found there had been failings “in some aspects of the care” provided by the Trust shortly before he died.

And while they couldn’t conclude that the failings led to his death, they confirmed that NEP had “missed opportunities” to keep the 19-year-old as fully supported as possible.

For the last eight years, his sister, Amanda Cook, has asked the question of why her brother wasn’t given more care during his hour of need.

“He wanted the help”

Growing up in Tiptree, Essex, Amanda claims Glenn was assessed for ADHD but his condition “wasn’t taken seriously”.

The PHSO report confirmed he was later diagnosed with an unstable personality disorder and had a history of anxiety, self-harm, suicidal thoughts, anger issues and substance misuse.

Glenn attended his sister’s wedding just two months before he died

But besides the problems he had, Glenn was a “lovely” person, his sister says.

“He had his issues but as a person, he was really caring and always the first to help someone out if he saw them in trouble,” Amanda said.

“He had hundreds of friends, he was funny and he was into his computers. That’s eventually what he wanted to work on, fixing computers and putting them back together.

He did have anger issues and he was very hyper, and looking back at it now I think Glenn was autistic but it was never picked up.

“When he was at secondary school he was getting anger management help but as soon as he left there was nothing, which is when the issues started coming in.”

Amanda explained that Glenn started taking “legal highs” to help him cope as he believed prescription medication wasn’t sufficient for managing his condition.

She also claimed that he would want to harm himself if he consumed certain types of alcohol.

But as his mental health began to worsen, Glenn was referred to the Lakes and he was under NEP’s care, which has since merged into the Essex Partnership University NHS Trust, when he died.

“He asked for the help, he wanted the help,” Amanda said.

The fight for a public inquiry

In November 2012, Melanie Leahy’s son Matthew was found hanged at the Linden Centre in Chelmsford just a week after being admitted under the Mental Health Act.

She has been pushing for a statutory public inquiry, through which witnesses can be made to give evidence under oath, into the county’s mental health services ever since.

According to Melanie, it’s the only way the affected families will achieve justice for their loved ones.

There are now around 20 Essex families supporting the fight for an inquiry, all of whom have lost a relative during or after being under the care of a mental health service, but the number is growing.

The group has now secured the support of Hodge, Jones & Allen Solicitors who have agreed to work on a pro bono basis to try to secure a public inquiry.

Nina Ali, Partner at HJA, said: “HJA is intent on helping these families secure the justice that they deserve.

“It is essential to get to the truth of what happened – all those families whose loved ones died whilst they were under the care of Essex mental health services are owed answers for their loss.

“A public inquiry is needed to ensure that a comprehensive and in-depth investigation is carried out and those responsible are held to account. It is only then, that things can and will begin to change for the better.

“We urge all affected families and individuals to get in touch with HJA. The call for a public inquiry is to include everyone affected by the failings of Essex mental health services: families of children, adolescents, adults, and the elderly who have died and individuals who have been through ‘the system’ and suffered but survived.”

Priya Singh, Associate at HJA, claims: “It is not only families of the bereaved who are coming forward but also ex-patients from whom we’ve heard shocking reports of abuse suffered by the victims whilst in care. These stories are harrowing.

“Vulnerable people have entered what are meant to be centres of trust and safety – a number voluntarily submitted themselves for help – only to be abused and exploited by some professionals who should protect them.

“They come in with mental health issues and leave – if they leave – in a much worse off state than before.

“No family, no individual should ever have to go through that. These families have been failed by the organisations that are set up to treat and care for patients.”

On June 19, 2012, Glenn was admitted to the Lakes after he overdosed on prescription medication and drank bleach, according to the PHSO report.

But he was discharged just three days later and was put under the care of the Trust’s Crisis Resolution and Home Treatment team (CRHT) who visited him five times over the course of the next ten days.

The last of those visits came on July 3 – four days before Glenn died – when they discharged him from the service back to outpatient care.

The PHSO report found that while this discharge was appropriate, Glenn had experienced two crises in the last six months and was therefore “at risk of further crises and impulsive self-harm”.

While there was evidence of a risk assessment and management plan at this point, the report found it “was not sufficiently detailed or robust”.

“A little while down the line he was doing really well,” Amanda said. “He had a girlfriend and we got him housed in Chelmsford, then nearer us in Colchester in temporary accommodation.

“He’d stopped drinking and then all of a sudden, within a couple of days, on the Friday night [July 6] he had a panic attack.

“He phoned the crisis team who told him he was phoning too much.,” she claimed. “He rang a friend and told them that.”

During the early hours of the Saturday morning, Glenn overdosed on prescription medicine and his death was recorded as accidental by the coroner at his inquest.

Amanda said: “He was trying to get his flat nice and was looking for a job, but I think he’d forgotten how much he was meant to take.

“He had his medication, went back onto his bed and passed away.

“My mum had gone round on the Saturday morning because no one could get hold of him, I was away that weekend so I didn’t know any of this was going on until I got the call.”

The PHSO report went on to explain that there was no mention of “impulsivity” in the risk documentation, despite this “probably being the biggest ongoing risk factor” for Glenn.

‘He was literally alone’

On the Monday (July 9), Amanda claims Glenn was meant to be moving into assisted living accommodation under the care of NEP.

She said: “My big issue now is that if he needed supported living, why was he discharged a week earlier with no interim care plan?

“Surely he shouldn’t have been left alone if he needed assisted living. He didn’t have that care plan in place but he was under the care of NEP.

“The only reason he was waiting was because this place was being refurbed and was having new carpets put in.

“That week he was discharged, he was doing well, he just wanted to sort himself out. Why wasn’t he left in the Lakes until they’d got that place for him?

“He was literally alone.”

Glenn was due to move into assisted living accommodation

Amanda was just 23 when Glenn died.

He had attended her wedding just two months before, and his death was difficult for Amanda to accept.

“We had a few meetings with the Lakes’ management and they came to my house just after Glenn had died,” she said. “But I was 23 and I didn’t really know what was happening or what was wrong with his case.

“It’s only recently that I’ve learnt about the interim care plan. It was more like I was asking ‘why didn’t you help him?’

“But now I can see there was a bigger issue on the other side where they failed him with his care.”

Glenn had been in and out of The Lakes Mental Health Hospital in Colchester during the last few years of his life

In a letter sent to Amanda from the Trust in February 2016, following the PHSO’s investigation, they acknowledged the failings and recommendations set out in the report.

These included the fact that there was “no evidence” of a detailed risk assessment being carried out when Glenn was discharged from the Lakes, and the omission of “impulsivity” from the CHRT team’s final risk documentation.

An Essex Partnership University NHS Foundation Trust spokesperson said: “We extend our deepest sympathies to Glenn’s loved ones.

“Since EPUT was established in 2017 our top priority has been to continuously improve patient safety, and we work with every patient to create a personalised care plan when they are admitted which includes planning and support for when they leave hospital.

“We continue to cooperate fully with ongoing investigations into the care of patients under the former North Essex Partnership University NHS Foundation Trust.”

As a result of the PHSO’s investigation, Amanda’s complaint about the care and treatment provided to her brother was partially upheld.

‘We’ve got a bit of hope now’

Amanda has now joined the fight for a statutory public inquiry into the failings of Essex’s mental health services.

Together, the families claim it’s the only way they will secure the truth and justice for their loved ones.

Amanda said: “I didn’t really know what to do after the inquest but it wasn’t until Mel got in touch a good few years ago to say that Glenn had been let down.”

A public inquiry would help get people from the outside to really look at the cases.

“Everyone reads the stories and feels sad but no one’s there to do something about it.

“Over the last few years we’ve all been going round in circles but we’ve got a bit of hope now.”

Credit : Elliott Hawkins

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