Michael Briley v Leicester Partnership NHS Trust
| Jurisdiction | England & Wales |
| Judge | James |
| Judgment Date | 09 June 2023 |
| Neutral Citation | [2023] EWHC 1470 (SCCO) |
| Court | Senior Courts |
| Docket Number | SCCO Ref: SC-2019-BTP-000495 |
[2023] EWHC 1470 (SCCO)
COSTS JUDGE James
SCCO Ref: SC-2019-BTP-000495
IN THE HIGH COURT OF JUSTICE
SENIOR COURTS COSTS OFFICE
Thomas More Building
Royal Courts of Justice
London, WC2A 2LL
Mr Joseph Buckley, Costs Lawyer (instructed by Bhatt Murphy) for the Claimants
Mr Matthew Smith, Counsel (instructed by Acumension Limited)
Apology
This matter was heard as long ago as 21 September 2020 when I heard it during the Covid-19 Pandemic. Entirely regrettably, and due to no fault of either party, it has taken until now to produce this Judgment. This was partly due to the Covid-19 pandemic and the disruption it caused but also due to other factors of which the parties are aware but which I do not include here, not least because whilst those factors explain the delay, I readily accept that they do not excuse it. I can only apologise which I do with sincerity and gratitude for the forbearance which the parties have shown. The parties were represented at the hearing by Mr Joseph Buckley for the Claimants with Ms Megan Phillips, the Solicitor who acted for the Claimants at Bhatt Murphy and who was able to assist me with various factual issues from the case, and Mr Matthew Smith (Counsel for the Defendants). All of the advocates were very helpful and I am grateful to them for their attention to detail in this case.
Background – lead up to death of Amanda Briley
This case involves the tragic early death of Amanda Briley (‘Amanda’) a young woman born on 25 August 1996, who passed away on 28 December 2016. Amanda began suffering from self-harming behaviour and mental health difficulties around the age of 12 and was referred to Child and Adolescent Mental Health Services (“CAMHS”), where she was under care of the First Defendant since 2013. She was home schooled, given the difficulties she faced attending mainstream education. At 15 years of age, Amanda was diagnosed with Asperger's Syndrome, later receiving a further diagnosis of emotional unstable personality disorder. From a young age, Amanda had multiple inpatient stays with CAMHS and at the Bradgate Mental Health Unit (‘the Bradgate Unit’). From 2012 to 2016, Amanda suffered numerous serious self-harm and suicide attempts and was admitted to several mental health units, including in crisis.
Amanda was referred to the PIER Team (Early Intervention and Psychosis Service) in January 2014 as it was thought that her presentation may be due to some form of psychosis. Following an assessment in October 2014, Amanda remained with the PIER Team given the diagnosis of psychosis could not be wholly ruled out. She remained under their care during her time at the Bradgate Unit and until her death. Their contact with Amanda was extensive as was their communication with the Bradgate Unit. During 2016, Amanda's mental health and behaviour worsened and it was no longer safe for her to remain at home given the self-harm and suicide attempts. Consideration was given to whether her actions were intended to provoke a response from them and therefore a form of communication/‘cry for help’ given her Asperger's Syndrome rather than being deliberate attempts to end her life.
Through PIER Amanda was admitted to the Bradgate Unit (Heather Ward) following an incident of crisis on 25 January 2016, but being relatively stable during this time Amanda was discharged from the Bradgate Unit on 16 February 2016, albeit without consultation with her PIER workers.
Amanda remained under the care of mental health services and PIER but throughout April 2016, her mood fluctuated. In addition, she wished to reduce the Olanzapine that she had been prescribed given the side effects she was suffering. The crisis team arranged a planned admission to the Bradgate Unit and this was escalated when it became clear that Amanda's distress was increasing; she was communicating that she was unable to keep herself safe, did not want to take her medication anymore and felt hopeless about her future. She was admitted on 7 May 2016 to Ashton Ward. A reduction in Olanzapine continued and, throughout this time, Amanda was attending autism outreach, an educational establishment, and was therefore on leave for that attendance. Amanda was officially discharged from the Bradgate Unit on 2 June 2016.
On 3 June 2016, Amanda took an overdose and made her way to a motorway bridge. On the way she called an ambulance. Amanda had previously attempted self-harm through jumping off motorway bridges, including one instance in which she fractured her spine. Amanda was subsequently readmitted on 4 June 2016 to the Bradgate Unit. In addition, at this time Amanda began to report again sensory and auditory hallucinations and a re-emerging of a character whom she referred to as ‘Declan’ who had featured previously in Amanda's ‘hallucinations’, including her reporting that she had been raped by him at the age of 13 but who (on occasion) she had also described as her boyfriend.
In June 2016, PIER met with those providing Amanda's care at the Bradgate Unit and documents were completed as requested by the ward applying for funding for specialist treatment and care for Amanda. It was recognised by both PIER and the consultant psychiatrist in charge of Amanda's care, Dr Pingili, that the complexity of her needs in terms of her Asperger's Syndrome and other diagnoses far exceeded the resources of the ward where she was, and that a more appropriate specialist placement needed to be identified. Numerous attempts were made to locate a suitable establishment, somewhere that would be able to work with Amanda for a psychological and functional approach and which could also meet the needs presented by Asperger's Syndrome, in addition to ensuring that she remained safe.
Amanda continued to self-harm throughout this time, including in the presence of staff members. She was predominately on level 1B and 1A observations, occasionally briefly dropping to level 2 observations. She reported to numerous individuals but she felt safe when there was someone with her. Level 1B observations involved an individual being in the room with Amanda and Level 1A involved an individual being constantly within arm's reach of her. Ligature attempts were also attempted throughout this period. On 16 July 2016, Amanda was placed on Section 5(2) of the Mental Health Act following a ligature attempt on the ward. She was subsequently detained under Section 2 of the Mental Health Act on 18 July 2016, and this was regraded to Section 3 of the Mental Health Act on 12 August 2016.
Amanda was seen in a ward round on 8 September 2016 and her observation levels were reduced from intermittent to general. The level of observations was then increased to level 2 10 minute observations, with a view to reducing further, but on 9 September 2016, Amanda attempted to ligature with her trousers at 12.40pm, and again ligatured at 15.30pm with earphones. There was a further serious incident on 11 September 2016 while Amanda was an inpatient on Beaumont Ward. She was on level 2 intermittent observations and found on her bathroom floor having tied her trousers around her neck several times. She required external hospital treatment and fortunately recovered. There were serious concerns in relation to the failure of any investigation to take place following that incident which was due to the investigator ‘forgetting’ to complete the investigation.
Attempts by PIER to obtain a suitable placement for Amanda continued and failures in relation to obtaining the necessary funding involved a delay in funding being applied for and subsequently granted. The delay lasted from 24 August 2016 until 8 November 2016, at which point a suitable placement was located for Amanda in Warrington. This was only resolved when PIER contacted NHS Arden and Greater East Midlands Commissioning Support Unit, given the lack of information about funding for a bed. It was at this stage that PIER were informed that nothing was known about an application for funding, with the person responsible for actioning the request having left the post in recent weeks and no-one having taken over progression of it. Funding was finally secured for a suitable placement for Amanda on 28 November 2016, one calendar month before she passed away.
Throughout this time, it was the opinion of all involved in Amanda's care that her placement on Bradgate Unit was wholly unsuitable for her complex needs. This was confirmed in the witness evidence from the warden matron at the Bradgate Unit. The placement was not intended to be and should never have been long term. Amanda was allowed very little leave given risks to herself from June until December 2016; leave took place on only a handful of occasions and she was always escorted. However, in December 2016 at a ward round meeting, the possibility was raised of Amanda going home for Christmas day. Once leave was mentioned, on 17 December 2016, a detailed plan regarding overnight leave for 24 December 2016 was made in collaboration with Amanda's named nurse, Zahra Makhany. The plan working up to leave on 24 December 2016 was set out in a care plan to be approved by a psychiatrist in the multi-disciplinary team.
The plan was also put on Amanda's bedroom wall, which was particularly important as Amanda's diagnosis meant that it was incredibly important for her to know a plan for what was going to happen on a daily basis and also for that plan to be followed. Any change could lead her to experience extreme confusion and distress.
The multi-disciplinary team agreed the plan on 20 December 2016. The plan included details...
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