Bryan and Mary Andrews: Prevention of Future Deaths Report

Mental Health related deathsOther related deaths

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Date of report: 04/10/2024 

Ref: 2024-0532 

Deceased name: Bryan and Mary Andrews  

Coroners name: Tanyka Rawden 

Coroners Area: South Yorkshire West 

Category: Other related deaths | Mental health related deaths 

This report is being sent to: Sheffield Health and Social Care NHS Foundation Trust

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Sheffield Health and Social Care NHS Foundation Trust
1CORONER
I am Tanyka Rawden, Senior Coroner for the Coroner area of South Yorkshire (West). 
2CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act  2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3INVESTIGATION and INQUEST
On 28 November 2022 I commenced investigations into the deaths of Bryan Andrews aged 79, and Mary Andrews aged 76. The investigation concluded at the end of the  inquests on 2 October 2024. The conclusion of the inquests was unlawful killing. The  medical cause of death was: 
1a. Multiple stab wounds. 
4CIRCUMSTANCES OF THE DEATH
On 27 November 2022 Bryan and Mary Andrews died at their home address of [REDACTED] due to multiple stab wounds inflicted by their adult son.
Their son had epilepsy caused by an area of abnormal brain development in the right frontal lobe. He continued to have regular seizures despite the medication he was  taking. 
He had a documented history of postictal psychosis. The Court heard his frontal lobe epilepsy created a risk around how he responded to experiences of postictal  psychosis. 
His mental health had deteriorated significantly in the two years before his parents  died. Seven months before his parents died, he reported thoughts of wanting to kill someone. 
In police interview, he admitted to killing his parents and attempting to end his own life by inflicting a knife wound in his abdomen. 
He pleaded guilty to murder on the grounds of diminished responsibly and was sentenced to an indefinite hospital order. 
5CORONER’S CONCERNS 
During the course of the inquest the evidence revealed matters giving rise to  concerns. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows. –

There was a lack of communication between services about the relationship between  the diagnosis of epilepsy and the psychotic symptoms experienced by the person  responsible for the deaths. 
This led to significant time lapses in treatment and rejection of referrals, most notably:

i. On 18 November 2020 an urgent referral was made to the Single Point of  Access Team by his General Practitioner, concerned about his prolonged  suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the  Improving Access to Psychological Therapies Service. 

ii. On 20 November 2020 his General Practitioner referred him to the Single  Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines. 

iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the  Improving Access to Psychological Therapies Service offered work on living  with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a  request to the General Practitioner for the mental health nurse in the surgery  to offer an assessment was appropriate. The surgery were not informed of this. 

iv. On 16 December 2020 the Single Point of Access Team received a referral  from a consultant neurologist requesting a medication review as his anxiety  levels were affecting his epilepsy treatment. It was felt that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist. 

v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the  emergency department. Once there he was assessed by the Liaison  Psychiatry Team. He was referred to the Home Treatment Team, but his  consultant neurologist was not informed. 

vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic  medication with his epilepsy medication was not carried out. 

vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of  psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team. 

viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was  unclear whether a new treatment episode had been opened. 

ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a  follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner. 

x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral. The referral was triaged on 22 November 2022 when he was invited to contact
the Single Point of Access Team for a further discussion.
6ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 
7YOUR RESPONSE 
You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 November 2024. I, the Coroner, may extend the period. 
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. 
8COPIES and PUBLICATION 
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

The family of Bryan and Mary Andrews.
Sheffield Teaching Hospitals NHS Foundations Trust.
[REDACTED], Consultant neurologist.
[REDACTED], Domestic Homicide review author.
 
I am also under a duty to send the Chief Coroner a copy of your response.
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 by the Chief Coroner. 
94 October 2024 
Signature
Tanyka Rawden H.M Senior Coroner for South Yorkshire (West).