Tragic case involving failures in community mental health care by Berkshire NHS Foundation Trust | Fieldfisher
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Case Study

Tragic case involving failures in community mental health care by Berkshire NHS Foundation Trust

Deborah Nadel settled a difficult and tragic case on behalf of the estate of a 29-year-old man who died following several years of recognised mental health difficulties.

At the time of his death, Mr T was under the care of the Berkshire Healthcare NHS Foundation Trust, specifically the Reading Early Intervention in Psychosis service (EIP).

As his health deteriorated, a care plan that included fortnightly visits from an EIP care coordinator lapsed, no review by a psychiatrist took place, and other failings including a failure to put in place a Care Programme Approach in accordance with NICE Guidelines occurred. 

The care coordinator failed to record her attendances on several occasions in Mr T's medical records. The family raised repeated concerns that Mr T's health was seriously declining and that he was not taking prescribed medication.

Information shared by the family about Mr T's health was not properly considered and recorded in the notes by the treating team and it was alleged the treating team generally failed to properly treat Mr T according to its duty and NICE guidelines, which resulted in his death. 

Once instructed, Deborah and her team that included Sarah Kingsley-Fried and barrister Jo Moore supported the family at inquest and pursued a claim against the Berkshire NHS Trust for failures in community mental health care. 

While admitting failures in relation to referral to a psychiatrist and not keeping proper documentation of the visits made by the care coordinator, the Trust sought to defend the claim on the basis that these failings would not have avoided Mr T's death. 

Further detailed investigations had therefore to be carried out and detailed particulars of claim based upon expert evidence from a psychiatrist and psychiatric nursing expert were served informally along with settlement proposals. Just before court proceedings were issued, a settlement was reached.

Following settlement, the family said: 'From my first contact with Fieldfisher, and particularly Deborah Nadel, I felt listened to and cared for.'

'This was a terrible time of our lives. I knew my son had been wronged but as a family we were devastated and so despite being an experienced professional myself I felt completely lost. Deborah, and team, gave me confidence to face the Coroner’s inquest and ask the right questions thus ensuring the conclusions gave a full and frank reflection on the care my son received from the Trust.'

'The relationship with Fieldfisher always understood the gravity of the loss my family felt and sought to minimise the impact and pain of further investigations whilst following through professionally and assertively with the Trust.'

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For further information about medical negligence claims, please call Deborah Nadel on 03304606750 or email


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