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Senior Coroner Finds That Young Man Taking Own Life After Being Discharged “Was As Predictable As Night Follows Day”

24 Aug 2021

Negligent healthcare services lead to tragic suicide of young man

On 25 June 2018, Mr Reece Lapina-Amarelle, 20, took his own life by jumping from Beachy Head, Sussex. Sussex Partnership NHS Trust have just settled a civil claim after a three year fight by his family for justice. Reece had a longstanding psychiatric history with a diagnosis of Emotionally Unstable Personality Disorder and also Post-Traumatic Stress Disorder. He had attempted suicide a number of times previously, most recently prior to his death on 13 June 2018 when he had been intercepted by Police on his way to Beachy Head. He had also previously drunk bleach, ran into upcoming traffic, and jumped out of his bedroom window in an attempt to hang himself, breaking his leg whilst doing so. After he had been intercepted on 13 June 2018, he was sectioned under Section 3 of the Mental Health Act. The care plan at that time recommended a long period of sectioning due to Reece’s long history of self-harm. Reece was admitted to Bodium Ward, part of Sussex Partnership NHS Foundation Trust in Eastbourne, East Sussex. On 22 June 2018, a Section 117 Discharge Meeting was held during which Reece expressed suicidal thoughts, voices, and intentions to go to Beachy Head once he was discharged. His supportive parents were not made aware of the meeting or provided an opportunity to attend. Once they found out about the planned discharge, they voiced their concerns to the Trust. However, their calls were not returned over the weekend. Reece continued to voice suicidal thoughts but despite this he was discharged on 25 June 2018. Upon leaving the Trust, he refused to accept his Discharge Care Plan or his medication. It was recorded in his medical records that he said that he “Doesn’t need any of these”. The parents’ calls had still not been returned by the Trust and therefore they were not present to collect him, despite saying that they would like to be. Mrs Lapina-Amarelle then received a text message from her son saying that he loves her. She had returned the call expecting him to still be in hospital, only to find that he was on his way to Beachy Head. The Police were dispatched and engaged with Reece at the top of Beachy Head, however, were not able to talk him down, and Reece eventually stepped off the edge taking his own life, less than an hour after he had been discharged. The story is particularly tragic, because Reece’s 18 year old brother, Kyle, had taken his own life 8 months earlier by jumping from Beachy Head. The family were unaware of Kyle’s mental health deterioration which is thought to be due to the strain of witnessing Reece’s multiple admissions and suicide attempts over the previous 18 months. Kyle had voiced concerns about the effects Reece was having on their younger brother of 16 years of age and the strain on the family. An internal investigation by Sussex Partnership NHS Foundation Trust has found that a clear Discharge Care Plan was not formed as to what support would be available for Reece once he was discharged into the community. They accept that Reece’s parents were not contacted and that they should have been regarding the discharge and an apology was provided to the family regarding this. Whilst hearing the inquest on 25 April 2019, Senior Coroner, Mr Alan Craze, commented that “Reece doing what he did was as predictable as night follows day”. He went on to confirm that he would be preparing a Regulation 28 Notice which would go to the Trust, NHS England, and The Secretary of State for Health, asking them to explain what action they would be taking to prevent future deaths. The Corner further commented it was “Difficult to think of a more stark case which should be brought to the attention of the authorities”. After the inquest, due to the family not feeling that the failings were being taken seriously enough by the trust, a civil case was pursued for damages arising out of Reece’s death. It was argued that by failing to keep him safe the trust had breached Reece’s ‘right to life’ under Article 2 of the Human Rights Act. The claim was settled in June 2021. Christina Lapina-Amarelle, said in response to her son’s death,

“Anyone who knew Reece prior to his mental health deterioration would describe him as a beautiful person both inside and out who would always smile and want to make people laugh. Unfortunately, his mental health and suicidal thoughts began in early 2016 and not only got worse as time went on, he became a different person. Without continuity in his care and support from the Trust in learning how to deal with his mental health issues, his illness then spiralled and was made worse by his brother’s death in Oct 2017. The week leading up to his discharge anyone who spoke to Reece or met him would say it was the wrong decision and he was not ready or in a fit state of mind to be discharged. We telephoned the ward nurse on Friday after Reece told us of a meeting the Ward held with him to discuss discharge plans for the Monday 25th June, and voiced our concerns which were unanswered. What hurts us the most is we were denied any opportunity to speak on his behalf when the Trust were considering his discharge and again the opportunity to collect him when they had released him on the 25th June 2018, which was a specific request I made in my call to them on the Friday. This was in contradiction of the admission care plan set by the ward Doctors in May 2018 which said that they wanted the family more involved. We feel very let down by the Trust. We are speaking out about Reece’s situation as there is not enough being done for young adults who are suffering with their mental health. Our local NHS Trust seems to rely heavily on community services, which are very limited.. This in our opinion needs to change as a person’s mental health needs can vary depending on the person and severity of their illness, so more services whilst admitted to a hospital environment should be considered which would prepare those individuals for discharge which they could then continually manage within the community.“

In an apology letter to the family Samantha Allen, Chief Executive, for the trust said “as Chief Executive of Sussex Partnership NHS Foundation Trust I want to say how very sorry I am for the loss of your son, Reece……I am sorry Reece was not referred to the Trust Wide Risk Panel to support the decision making on his discharge and treatment plan. I am also sorry that you were not at the discharge meeting on 22.06.18 and that there was a delay in returning your call between 22.06.18 and 25.06.18” Ben Davey, Senior Chartered Legal Executive of Dean Wilson Solicitors LLP, who acted for the family throughout said “This case just shows the catastrophic consequences of getting big decisions wrong. As part of the claim we obtained evidence from an independent psychiatry expert who said that it was negligent to discharge Reece when the trust did. This was a young man in serious need of support and unfortunately the system has failed him. We never received a satisfactory answer to explain why Reece was allowed to leave a secure psychiatric unit by himself whilst continuing to voice suicidal ideas.” 

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