A coroner has concluded that the death of 23-year-old Richard Flight while he was in the care of a specialist mental health unit was contributed to by “a dysfunctional information chain and system for identifying suspected overdose cases”.

Having been in the care of The Redwoods Centre in Shrewsbury – run by the Midlands Partnership NHS Foundation Trust – Richard Flight died at Shrewsbury General Hospital on 6th October 2021, just days after he had taken a mixed overdose of drugs. But the pathway of care that he had received has been found to have been fundamentally flawed in an Inquest which has concluded this week.

Richard Flight was described as being bright, loyal and with a good sense of humour, and he loved his work as a trainee chef working in pubs and restaurants and was happily employed at a specialist coffee roastery at the time of his death. He also had a history of mental health issues and had struggled with alcohol and drug dependency since his teens. He had undergone rehabilitation and recovery in recent years through Narcotics Anonymous but had never managed to receive adequate mental health support from the system.

Mental health care failings

In the period before his death, Richard had successfully abstained from both drink and drugs, but his mental health had still declined. On 18th September 2021 he called the police because he was feeling suicidal having relapsed into drink and drug use. Richard was detained under the Mental Health Act and was transferred to the Laurel ward of The Redwoods Centre – a specialist mental health facility – but was only admitted as an ‘informal patient’.

This status would become critical in how Richard’s tragic story unravelled. On both the 24th and 25th September, Richard was allowed to leave the centre and go into town, and the next day he was reported by a nurse as being “drowsy and unsteady”. A subsequent urine sample revealed the presence of THC/cannabis in his system. Later that night, and again in the morning of 27th September, a duty nurse reported that Richard again appeared to be under the influence of drugs, and another test revealed the presence of cocaine and amphetamines.

Despite these discoveries, Richard was again allowed to leave the centre that day between 4.30pm and 8.30pm. That night he appeared to be panicked and alarmed and an attending nurse contacted a doctor, but the doctor declined to visit Richard. A nurse then administered detox medication which, under centre rules, meant that Richard would need to be regularly observed and checked. However, he was left unattended for several hours.

At 4.00am on 28th September Richard was unable to stand but was left in a lounge area and not taken to his room. No clinical checks were made and by 9am he was completely unresponsive. Richard was then transferred to Shrewsbury General Hospital where his health rapidly declined and he died in hospital on 6th October.

Coroner conclusions in the Richard Flight Inquest

The coroner concluded that there had been missed opportunities to provide the medical attention that Richard needed, and these could possibly have prevented his death. The official reason for death was given as “death caused by brain injury relating to mixed drug overdose”. But the coroner also said:

  • “There was reason to suspect Richard was taking illicit drugs either when on town leave or on the ward.”
  • “Opportunities were lost for Richard to receive medical attention” on two occasions at The Redwoods Centre, in the hours before he was taken to hospital
  • “On the second occasion it is likely Richard would then have been admitted to Royal Shrewsbury Hospital to receive treatment from which he may have recovered.”
  • “A dysfunctional information chain and system for identifying suspected overdose cases may have contributed to his death.”

Commenting upon the conclusion of the Inquest, Richard’s family said: “We have waited over a year for the Inquest. This has been hard to bear and has impacted heavily on our ability to grieve. From the beginning we feel we were up against an organisation that did not appear to care about our family. Clear systematic failures in the processes were exposed that led to critical gaps in communication between senior and junior staff and between day and night shifts. We feel that the Trust let the family and our son down in these matters and have added to our pain and suffering.”

Missed opportunities may well have saved Richard’s life

There were, however, problems identifying witnesses to attend the Inquest, and this along with the systematic flaws discovered by the Inquest, has led Richard’s family to progress the matter further. They added: “We will not leave this here. We will be contacting the quality regulator for the Trust to request they investigate the serious matters that came to light at the inquest and see if they are satisfied with the improvements the Trust say they have made. We will do this for the sake of other families who we hope will never have to experience anything like this in the future. But for now, we will try to start grieving properly for the loss of our much-loved son, brother, grandson and friend.”

Richard’s family were represented by Ison Harrison solicitor Ruth Bundey in her role working with the Inquest Lawyers Group. Inquest have called for a statutory public inquiry into deaths in mental health settings nationally, and Ruth commented:

“Discovering the identity of relevant witnesses responsible for Rich’s welfare has been like pulling teeth: an inexcusably painful process for his family to experience. Had they known of the incompetence and lack of information sharing at the Redwoods, they would have done all in their power to ensure that their son, a voluntary patient, left immediately. We are grateful to the coroner for his careful analysis of the contradictions which emerged in evidence, and his recognition of the missed opportunities for rendering care which may well have saved Rich’s life.”

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