Yousef Shokri-Gharab

Date of report: 14/10/2013 Ref : 2013-0239 Deceased name : Yousef Shokri-Gharab Coroners name : Andre Rebello Coroners Area: Liverpool Category : Hospital Death This is being sent to: Mersey Care NHS Trust

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive, Mersey. Care, NHS Trust, Windsor House

40 Upper Parliament Street Liverpool L8 7LF

1 | CORONER

| am André Rebello, Senior Coroner, for the area of Liverpool

2 | CORONER’S LEGAL POWERS

| 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.

3 | INVESTIGATION and INQUEST

On ‘st July 2013 | commenced an investigation into the death of Yousef SHOKRI- GHARAB, Aged 34. The investigation concluded at the end of the inquest on 11th October 2013. The conclusion of the inquest was

la Morphine (Heroin) Toxicity

Yousef SHOKRI-GHARAB was certified as having died at the Royal Liverpool University Hospital on the 20th June 2013. He was an asylum seeker from Iran and his request for asylum status had been rejected by the Home Office. He was going through a tribunal appeal against this decision at the time of his death. He was suffering from a mental illness which, though stili under assessment, was in the nature of an emotional unstable personality disorder. He had difficulty in coping with stress, had poor coping strategies, difficulty regulating his emotions and had hallucinations. He had self-harmed in various ways including overdoses of medication, banging his head, striking hard objects with his hands and fists and cutting himself with parts of a sharp tin-can. It remains unclear as to whether his self harm was purely part of his mental disorder or attention seeking or to manipulate situations. It is unclear as to whether he intended to end his life through self harm or whether comments about ending his life were made to exaggerate his demands. He required in-patient treatment for this disorder, to which he agreed without need for recourse to the statutory powers. He reported that he had previously suffered and received treatment for substance misuse, including heroin, but had been abstemious for a year and a half. He was on level two observations which precluded him having unescorted leave from the Windsor House until 13th June, when a multidisciplinary team appropriately moved him to level one observations enabling leave. Unfortunately “the Policy and Procedure for leave for an informal patient" in the hospital, ratified in October 2006 and due for review in October 2007, remained the current policy in June 2013, it not having been reviewed. Permission for leave on the 15th, 16th, 17th 19th and 20th June 2013 were authorised after consideration and risk assessment by nursing staff, without regard to the opinion of the Responsible Medical Officer (Consultant Psychiatrist). In this case it is found that this did not make any material difference to what would have happened had the policy been followed as the consultant psychiatrist confirmed that he would have approved of the leave granted. This would not necessarily have been the outcome in another case. On the 15th, 16th, twice on the 17th and on the

19th June, Mr SHOKRI-GHARAB returned from leave. There was no reason why he would not have been given leave to ostensibly visit the post office, Refugee Action and his solicitor on the 20th June to clarify payments of his asylum support allowance. It is unclear as to whether he attended at any of these places when on leave. He was found at about 12.15 pm in a collapsed state in a disused car park in Roscoe Street, Liverpool 1. Thereafter, he was attended by paramedics and taken to the Royal Liverpoo! University Hospital. At 13.25, after attempts at resuscitation, he was certified as having died. Post mortem analysis of blood revealed, amongst other substances, the presence of Morphine at 0.36 mg/L, 6-mono-acetyl Morphine at0.008mg/L, Codeine at .0.027mg/L. It is found that Yousef SHOKRI-GHARAB has died from the toxic effects of heroin. It is likely to be significant that he had been abstemious from opiates for 18 months and was likely to have lost any tolerance to opiates which he previously had.

CIRCUMSTANCES OF THE DEATH

Yousef Gharaab is an asylum seeker, his asylum seeker status has recently been reviewed and rejected. H s family have been concerned as he has shown suicidal intent, stating he will end his life by any means. He has recently been discharged from the Brunswick Ward at Windsor House on 31st May 2013. On Thursday 20th June 2012

and his partner {vere sleeping rough at the old car park junction of Oldham street and Roscoe sireet. They awoke at 12.15pm and noticed a male was on the floor, he looked asleep but John didn't recagnise him. John noticed his lips were purple and he wasn't breathing. Paramedics were called and conveyed Yousef to RLUH where he died short time later. i ond -onfirmed death not being treated as suspicious after visiting the scene and not finding any suspicious marks or injuries.

CORONER'S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. 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. —

The Mersey Care Policy and Procedure for leave for an informal patient was ratified in October 2006 and was due for review in October 2007. It has not been reviewed. The policy does not reflect practice. The policy needs to be updated immediately to protect patients and to be fair to employees of Mersey Care. To reflect current practice the policy should reflect amongst other matters that leave is permitted when observations are reduced to level 1 and there has been a multidisciplinary team consensus that a regime of leave is appropriate having consideration to (i) the deceased's vulnerability, (ii) the fact that the hospital had assumed responsibility for the patient's welfare and safety, including by the exercise of control, and (iii) the nature of the risk and whether it was “exceptional” rather than “ordinary”

The policy should include stressing the importance of documenting before leave the time of taking leave and when the patient is due back. The operation of the policy should be audited to ensure compliance.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd December 2013. |, 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons

The family of Yousef Shokri-Gharab The Home Office The Coroner's Society

| am also under a duty fo 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.

Jae

DATE SIGNED BY CORONER: 14" October 2013