NHS trust bosses have said sorry to the family of a patient, who died after being discharged from its care, after a three-year fight for justice.
The apology, from the Sussex Partnership NHS Foundation Trust, came as it settled a civil claim brought by the family of Reece Lapina-Amarelle.
Mr Lapina-Amarelle was 20 years old when he took his own life by jumping from Beachy Head on Monday 25 June 2018.
He had been discharged by the trust shortly before, having told the discharge team that he would head straight there.
East Sussex coroner Alan Craze criticised the trust and said: “Reece doing what he did was as predictable as night follows day.”
In the year before he died, Mr Lapina-Amarelle had spent time in Mill View Hospital, in Hangleton, which is run by the trust.
He also spent time in the Royal Sussex County Hospital, in Brighton, where he needed emergency treatment after breaking his leg during an unsuccessful suicide attempt.
The law firm Dean Wilson, which represented the family, said: “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 Wednesday 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 while doing so.
“After he had been intercepted on Wednesday 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 Bodiam Ward, part of Sussex Partnership NHS Foundation Trust, in Eastbourne.
“On Friday 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 Monday 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, (they) 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 eight 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.”
At the inquest on Thursday 25 April 2019, the coroner Alan Craze said: “Reece doing what he did was as predictable as night follows day.”
The coroner sent a “regulation 28 notice” 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 coroner said that it was “difficult to think of a more stark case which should be brought to the attention of the authorities”.
After the inquest, the family did not feel that the failings were being taken seriously enough by the trust and brought a civil claim.
It was argued that by failing to keep him safe, the trust had breached Mr Lapina-Amarelle’s “right to life” under the Human Rights Act. The claim was settled two months ago, in June.
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 (but) 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 October 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 (staff) held with him to discuss discharge plans for Monday 25 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 Monday 25 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 while admitted to a hospital environment should be considered which would prepare those individuals for discharge which they could then continually manage within the community.”
The trust’s chief executive Samantha Allen sent a letter of apology which 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 Friday 22 June 2018 and that there was a delay in returning your call between Friday 22 June 18 and Monday 25 June 2018.”
Ben Davey, senior chartered legal executive at 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 while continuing to voice suicidal ideas.”
