York family call for inquiry into TEWV after son dies during crisis

The family of a young man who died in a road traffic collision whilst suffering an acute mental health crisis have spoken out about the multiple failures in his care, and the inadequacies of the hospital trust’s subsequent investigation. 

Ben Stamp, a talented scientist and beloved son, died in August 2020 in York, whilst awaiting a visit from the Foss Park hospital's crisis home treatment team. 

The day before his death, Ben had been seen urgently at the hospital and was diagnosed with likely acute psychosis. He was judged to be at significant risk of harming himself but was sent home with his parents until a Mental Health Act assessment could be arranged later that day. 

Ben’s mood and behaviour were fluctuating and, by the time the team visited to undertake a Mental Health Act assessment, he was much calmer and more communicative.

The family believe that the team "made no attempt to discuss or explore Ben’s earlier assessment" and "failed to note" in their report the earlier diagnosis of a likely psychosis. They recorded only a diagnosis of a depressive episode. 

Ben's parents, Ronald and Rachel Stamp, have now joined calls for a full public inquiry into deaths at the trust, signing an open letter to the Prime Minister alongside other bereaved families. 

They said: “We were grateful that the first mental health practitioner recognised that Ben was suffering from a serious mental illness and that he was at high risk of harming himself and needed help.

“But because Ben wasn’t paranoid and delusional at the time of the later assessment, the team seemed to ignore his earlier episode – it later became clear that his initial diagnosis and assessment of being at significant risk were subsequently disregarded.” 

The family also reports that the team that undertook the Mental Health Act assessment also refused to leave a prescription for drugs that they said would provide rapid relief if Ben again became agitated and promised that someone would visit first thing the next morning, bringing those drugs with them. 

Ben’s parents said: “We wanted to believe that Ben had turned a corner and we hoped we could keep him safe until someone visited early the next morning. 

“Unfortunately, Ben deteriorated during the night and, in the early hours of the morning, he was once again suffering from delusions and expressing paranoid beliefs – he was very distressed and we knew that he needed urgent help from the mental health team.” 

Despite multiple and increasingly frantic calls made to the crisis team over several hours that morning, the promised early morning visit never happened. The family told The Northern Echo that their extreme concern was not escalated to a more senior and experienced clinician and no practitioner attempted to speak to Ben. 

Mr and Mrs Stamp said: “On Monday morning, Ben was again in crisis but nobody would listen to us. We phoned asking for urgent help just after 6am and again and again after that. 

“We had been promised the evening before that medication to calm him would be delivered early the next morning and, if that promise had been kept and someone had seen him early in the day, we believe he would still be with us.

"Neither the practitioner who first assessed Ben and recognised his likely psychosis, nor the practitioner assigned to Ben’s care on the day of his death, attended an important multi-disciplinary team meeting when cases for the day were discussed.

"Contrary to its policies and the department’s usual practice, the hospital failed to keep any record of the discussion of Ben’s case, and members of the team said they couldn’t remember what was said."

The mental health team, including the person allocated to see Ben that morning, were reportedly also unable to remember who gave the handover report for his care or recall what clinical information was provided and considered.

The family believe that Foss Park Hospital failed to follow its own policies, made errors in diagnosis and risk assessment, failed to make and communicate a proper care record and plan, and failed to respond appropriately to the many calls for urgent help from Ben’s family.

They said: “Ben was failed by a service meant to provide help to people experiencing a mental health crisis”. 

Following Ben’s death, the family feel that they struggled to get full and accurate information from the trust and were strongly critical of the subsequent serious incident review which they consider "flawed and misleading".

They added: “When Ben died, it felt that the hospital staff went to ground – they didn’t even contact us for several days.  

“When we did eventually talk to the person responsible for conducting a serious incident review, we were completely open and shared everything we knew about what had happened.  

“We told them that we knew there had been errors but that we weren’t interested in blaming any individuals – we only wanted to help the trust identify the things that went wrong so that they could be avoided in the future 

“Contrary to national guidance about the conduct of case reviews, the trust refused to share a draft of their serious incident report with us before it was finalised and ‘signed off’ – it raised more questions than it answered. 

“Getting further information to answer those questions was difficult – organisation of the clinical notes was chaotic, with different versions of reports appearing, and some entries indicated they had been ‘updated’ months after Ben’s death 

“When we asked for a copy of the pharmacy record for Ben’s prescribed drugs, we were sent the drug record for a different patient, including their name and address.” 

Before retiring, Ben's father, Mr Stamp, had long experience in the NHS and Department of Health, including being a member of the Quality Board of an acute care trust. He does not believe that the trust can change its course without an overhaul at the very top. 

He said: “We believe this trust is failing in its duty of candour and doesn’t understand the importance of learning from mistakes – unless the trust’s top team can change this culture, they will continue to fail those who depend on their care. 

“We learned from NHS England and NHS Improvement that they had investigated the trust’s procedures for undertaking serious incident reviews and identified over 50 areas requiring improvement – many of the inadequacies they identified resonated with our own experience of the review of Ben’s care, which was woefully inadequate.” 

Writing to the trust’s chief executive, Brent Kilmurray, a year after Ben’s death, Mr and Mrs Stamp said: “It is important that we make clear that we have no wish to pursue this matter through litigation, to seek compensation, or to seek to apportion blame to any individual.

"We do, however, believe that there were shortcomings in Ben’s care and that important lessons should be learned by the Trust to avoid similar incidents in the future.

Read more:

• Bereaved families call on Prime Minister for public inquiry into mental health trust
• An open letter to the Prime Minister calling for a public inquiry into TEWV
• 'They drove her to her death': Mother calls for inquiry into daughter's suicide

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"We have lost our son and can do nothing about it. In contrast, there will be future patients whose lives may depend on the systems of care that the Trust has in place.”  

A spokesperson at the Trust, said: “Our thoughts and condolences go out to Ben’s family.

“As an NHS trust, we have no role or influence on public inquiries. These are a matter for government. We fully accept the need for accountability and that currently comes in many forms, including regular inspections from the Care Quality Commission.”