Thetford man set himself on fire hours after hospital discharge
10:03 29 January 2014
A Thetford man died when he set himself on fire just hours after being sent home from hospital by mental health workers, an inquest heard.
Paul Aspinwall, who had a long history of psychiatric problems and substance abuse, had been found naked, sobbing and holding a knife at home and was taken to hospital to police in the early hours of April 16 last year.
However, when he was assessed by mental health professionals four hours later, they judged that he was not having a psychotic episode and told him his erratic behaviour was a result of “a lifestyle choices” related to his heavy use of alcohol and drugs including crack cocaine and heroin.
Later that day the 44-year-old was checked on by police, but at 1am the following day he set himself on fire outside his Walmington Court home, and died from 85pc burns.
At an inquest in Norwich yesterday, failures in communication between the drug and alcohol treatment team working with Mr Aspinwall and the Norfolk and Suffolk NHS Foundation Trust team responsible for his psychiatric care were highlighted.
Norfolk senior coroner Jacqueline Lake said it was “surprising” that drug and mental health teams were not working more closely given that psychiatrists were trying to reduce his prescription medication following a change in his diagnosis in February 2013.
An internal review of services at the trust has since led to the teams working together formally.
“It has been accepted on behalf of the trust that there were perhaps some gaps in liaison between different departments and that those difficulties are being dealt with,” she said.
Mrs Lake said she could not be certain Mr Aspinwall intended to end his life, recording a narrative conclusion that he died “as a result of his own actions while the balance of his mind was disturbed and while receiving treatment from the mental health services.”
Mr Aspinwall had become concerned that his anti-psychotic medication would be reduced or withdrawn after his diagnosis was changed on February 5 – from schizophrenia to an enduring personality disorder with multiple substance abuse – and his use of recreational drugs had increased.
Care worker Aaron Chipping, who carried out the hospital assessment on April 16, said Mr Aspinwall appeared “bright”, with no suicidal intent, and that there was “no evidence that [he] required a hospital admission”. He said Mr Aspinwall’s file showed that his fluctuating mood could often be explained by drug and alcohol misuse.
Consultant psychiatrist Dr Camilo Zapata said Mr Aspinwall did not show signs of psychosis so he had tried to reduce his medicine – which left Mr Aspinwall “scared”.
But he admitted he “didn’t really have any idea” what drug and alcohol teams were working on with the patient at the same time. “It wasn’t very joined up,” he added.
Speaking afterwards, Mr Aspinwall’s father James said he was “satisfied” with the verdict.
“Paul had a lot of problems all his life, and I’m not blaming anyone,” he said.
“Things could probably have been a bit better, but they did what they thought was right. They have a hard job to do, and I have no complaints.”
The trust has improved department links and staff training, along with faster access to crisis team staff, following the review.
Dr Jane Sayer, NSFT director of nursing, quality and patient safety, offered condolences to Mr Aspinwall’s family
She said: “I fully accept the coroner’s verdict, the findings of our own internal investigation and the external independent investigation. We have already implemented every single one of the reports’ recommendations and all have now been completed.”