Mental health services failed to check on 'deeply loved' grandad months before death

Staff were also found to have changed his records after his death

Mental health services failed to support a struggling Nottinghamshire grandad for almost four months before his death, an inquest has found. James Southern, known to friends and family as 'Jimmy', died from an accidental drug overdose at home in Cotgrave in May last year.

The 40-year-old, who had suffered with pain and anxiety since a motorbike crash in 2002, was known to local NHS mental health teams and spent almost a month in Highbury Hospital. However an inquest, which concluded on Tuesday, October 2, found his case had not been passed on when his care coordinator went on long term sick leave, and she did not try and contact him when she returned to work.

It also uncovered that staff had changed his clinical records after he died. Assistant coroner Sarah Wood said failings at Nottinghamshire Healthcare Foundation Trust (NHFT) "more likely than not" contributed to his death.

The trust apologised to Mr Southern's family and said it had referred a worker who amended the records to the regulatory body. In a statement on behalf of the family, law firm Rothera Bray said he had "a smile that lit up any room".

"He is described by his family as someone always on the side of the underdog and hated injustice," it said. "He was, in short, deeply loved and admired by those around him. His loss has therefore left a considerable hole in the lives of his friends and family."

Mr Southern, who at times self-medicated to cope after his motorbike crash, presented to mental health services in August 2022 suffering with hallucinations. He was admitted to Highbury Hospital on August 9 and discharged on September 1.

Ms Wood said there were errors in his records which "misled medical practitioners" and Mr Southern into thinking a care coordinator had been allocated. There was no contact at all between November 18 and January 16 and again from February 6 until his death on May 31.

The latter was because no cover was arranged when his care coordinator went on long term sick leave, and she did not attempt to contact him when she returned to work on May 3. Mr Soutern was found unresponsive by his father at home in Broadmeer, Cotgrave less than a month later.

The inquest also found evidence that records had not been uploaded in a timely manner and at times after death, as well as evidence that records were amended after death. Ms Wood issued a prevention of future deaths report following the inquest.

The assistant coroner said she was concerned about poor record keeping at NHFT, as well as the level of communication between workers. Diane Hull, executive director of nursing at the trust, said: “On behalf of the trust I once again offer our sincere condolences and apologies to James’ family and friends for their loss.

"We recognise that there were aspects of the care delivered to James that were not of the standard our patients deserve and for that we are truly sorry. When we became aware of the amendments made to clinical records we referred the clinician involved to their regulatory body, the NMC, and began a disciplinary process.

"We are working to address the other issues raised by the Coroner to improve the experience for patients now and in future.” Greg Almond, partner and solicitor at Rothera Bray LLP said: ‘Jimmy’s family are devastated by his passing, particularly as he leaves behind children and a grandchild, all of whom he loved and adored deeply, along with both of his parents, and a fiancée whom he was due to wed in December this year.

"Despite the gravity of their loss, they have shown great strength and dignity in their efforts to ensure Jimmy’s death was fully investigated."