Caroline Harris: Prevention of future deaths report

A medical cause of death could not be ascertained. 

I reached a Narrative Conclusion as follows:
‘Caroline Harris had a long-standing diagnosis of severe mental illness. In August 2022, she refused to continue taking her monthly antipsychotic medication, and her mental  health deteriorated. Information relating to Ms. Harris’ decision to stop taking her  medication, as well as concerns raised by Thames Valley Police about a decline in her  mental health, was not passed on to the Adult Mental Health Team. Consequently, they  were unable to supervise her adequately. On 26 July 2023, Caroline was found  deceased at her home. Although it has not been possible to ascertain a medical cause  of death due to decomposition, it is likely that she died from a natural cause,  exacerbated by self-neglect.’ 

Caroline attended a monthly clinic to receive her antipsychotic medication.  Evidence was given that at the time there was no clear process for passing information onto the  Adult Mental Health Team (AMHT) should patients not attend and/or decline to take their medication.  Had the AMHT been notified then evidence was given that they would have  undertaken intensive and assertive follow up.  Nor was Caroline’s GP notified of this  development.           

Oxford Health NHS Foundation Trust have reviewed their operating  procedures to address these concerns.    

The MATTERS OF CONCERN are as follows. –
In March 2023, Thames Valley Police passed on a report about Caroline to the Mult- Agency Safeguarding Hub (MASH) which raised concerns about her behaviour and  mental state and dishevelled appearance. The report stated that it was, ‘Shared in the interests of safeguarding as may be having relapse’.    

MASH undertook a review of the report and concluded that Caroline was not at risk but  may have needs for care and support from the local authority. The information was  passed to the Council’s Adult Social Care Team who in turn passed the information onto Caroline’s GP.  Evidence was given that the Adult Social Care Team were unable to  directly refer to AMHT, even if they had considered it necessary. As the GP was not  made aware that Caroline had declined to attend the clinic to receive her medication,  she saw no need to refer the Police report to AMHT.    

Evidence was given that AMHT took a different view regarding the Police report and  would have viewed the report as evidence of Caroline relapsing.  AMHT’s view was that such a report met the criteria for being shared with them, and with their knowledge of  Caroline’s past history of self-neglect and non-compliance with taking medication, it  ought to have been shared with them; and had it been done so it would have been  followed up assertively and urgently including undertaking home visits and the possible  use of compulsory powers under the Mental Health Act. 

My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate  interventions and to have taken steps to avoid a fatal outcome.                                                                  
You should consider a review of how such information is assessed and shared between the respective agencies.  

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 

I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.    

I may also send a copy of your response to any other person who I believe may find it useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted or summary  form. He may send a copy of this report to any person who he believes may find it useful or of interest.  

You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.