Rodney Dixon

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

James Healy-Pratt, HM Assistant Coroner for the area of East Sussex in response 
to a Regulation 28 Report to Prevent Future Deaths following an inquest hearing into the 
death of Rodney Dixon on the 17th to the 19th of May 2021 

1 

EAST SUSSEX COUNTY COUNCIL 

I am Mark Stainton, Director of Adult Social Care, East Sussex County Council, St 
Anne’s Crescent, Lewes, BN7 1UE 

2 

CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified as follows: – 

Mental Health Act assessments are conducted in East Sussex deploying clinicians from 
both from both ESCC and SPFT (Sussex Partnership NHS Foundation Trust) and 
independent clinicians such as psychiatrists. 

The training around Mental Health Act assessments, patient risk management, and their 
Assessors is sub-optimal.  Reasonable access to patient data by independent clinicians 
for MHA assessments need to be ensured prior to assessments. 
BACKGROUND 

3 

Rodney Dixon took his life on the 15th of July 2019 at his home in Eastbourne, during the 
course of a Mental Health Act assessment. 

The Assistant Coroner commenced an investigation into his death on the 23rd of July 
2019 which concluded following a three day Inquest on the 19th of May 2021. 

The Assistant Coroner reached a narrative conclusion that the cause of death was 
Hanging and that Mr. Dixon took his own life, following a deterioration in his mental and 
physical health. 

The Assistant Coroner requested that East Sussex County Council review its’ training in 
relation to Mental Health Acts assessments and “ensure there is clarity of understanding 
amongst all stakeholders that are involved in risk assessment”. 

Written submissions were welcomed in relation to this issue, and ESCC submitted its’ 
submissions on the 11th of June 2021. 

The Regulation 28 follows on from that. 

4 

DETAILS OF ACTION UNDERTAKEN. 

As a local authority, the Council is responsible for the recruitment, training, warranting 
and management of Approved Mental Health Practitioners (AMHPS).  The Council has 
no input into the recruitment or training of Doctors and other medical staff who practise 
in this area.  That is the responsibility of the Sussex Partnership Foundation Trust 
(SPFT) who have also been issued with a Regulation 28 notice. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Council has reviewed its’ training and documentation in respect of AMHPs 

Since the conclusion of the Inquest, the following actions have been undertaken:  

(1)  Leon Gooding (Head of Adult Social Care) hosted a meeting with all the 

Council’s Approved Mental Health Practitioners (AMHPs) to discuss the issues 
arising from this case.  During the meeting, It was agreed that the client in cases 
similar to that of Mr. Dixon should not be left unsupervised unless assessed to 
be of low risk. The Council’s Mental Health Act referral and Risk Assessment 
Forms have been updated.  They include a new section entitled “dynamic risk 
assessment”. 

A copy of this new assessment is attached hereto.  It is published on the 
Council’s internal website. 

It says as follows 

“All individuals must be risk assessed with the aim to ensure their safety for the 
entirety of the assessment process, up to and including admission. 

At no point throughout the assessment is the client to be left 
unsupervised unless assessed by the assessing team to be presenting 
with low current risk to self of others.   

It is the AMHP’s responsibility to ensure the assessing team has access to 
the most recent risk assessment and relevant client clinical history.” 

(2)  Yearly risk management training with Brighton University for existing AMHP’s 

has been arranged.  This is part of the annual training that AMHPs undergo 
anyway but it will now include specific training on risk management.  

(3)  The AMHP warranting and re-warranting process has been updated.  A dynamic 
risk assessment has to be completed and presented to the assessing team.  It is 
now part of the process that AMHPs undergo as part of the warrant and re-
warranting process. 

5.   DETAILS OF FURTHER ACTION PROPOSED 

The actions the Council has undertaken above will be regularly reviewed and 
updated/amended if appropriate 

6.  SAFETY OF THOSE ASSESSED UNDER THE MENTAL HEALTH ACT 

Every death by hanging is a tragic loss of life. The Council is committed to improving 
training for its AMHPs and in the way they conduct and implement Mental Health Act 
assessments  

The death of Rodney Dixon is a tragedy and the Council offers its’ sincerest 
condolences to the family.  

7. 

Signed      

, Director of Adult Social Care 

2

r~t:bj

Sussex  Partnership 
NHS  Foundation Trust 

Office of the Chief Executive 
Trust Headquarters 
Swandean 
Arundel  Road 
Worthing 
West Sussex 
BN13 3EP 

A member of: 
Association  of UK University Hospitals 

12 August 2021 

Mr Healy-Pratt 
Assistant Coroner for East Sussex 
Coroner's Office (East Sussex) 
Unit 56,  Innovation Centre 
Highfield  Drive 
St Leonards on  Sea 
East Sussex 
TN38 9UH 

Dear Mr Healy-Pratt 

Mr Rodney Dixon 

I write  in  response  to  your  Regulation  28,  Report to  Prevent Future  Deaths,  dated  21 
June 2021,  following  the Inquest into the death of Mr Rodney Dixon. 

I  was  very  sad  to  learn  of  Mr  Dixon's  death  and  I  personally  convey  my  sincere 
condolences to his family. 

I understand that Mr Dixon took his  own  life,  at  home  in  Eastbourne,  on  15 July 2019 
during  the  course  of a  Mental  Health  Act  (MHA)  Assessment.  I also  understand  that 
you  were  satisfied  that  those  carrying  out  that  Assessment  (the 
'Assessors') 
collectively  had  sufficient  information  to  make  the  decision  they  did  and  that  Mr 
Dixon's  decision  to  take  his  own  life  was  reasonably  unforeseeable.  However,  I 
recognise and  understand that you  are concerned  about potential future  risks that may 
present  themselves  to  other  patients;  specifically,  by  sub-optimal  MHA  Assessment 
training  and  the  accessibility  to  the  MHA  Assessors  of  relevant  patient  information 
prior to completing  MHA Assessments. 

Your office has helpfully shared the Response provided to you  by East Sussex County 
Council  (ESCC)  and  I  note  that  they  have  explained  their  responsibility  for  the 
recruitment,  training,  warranting  and  management  of  the  Approved  Mental  Health 
Practitioners  (AMHPS)  and  provided  details  of changes  that they  have  initiated. 
It  is 
regrettable  that  a  direct  discussion,  between  Sussex  Partnership  NHS  Foundation 

 Trust (the 'Trust')  and  ESCC,  about your concerns,  has  not occurred  as yet.  However, 
I  am  pleased  to  be  able  to  assure  you  that  the  Trust's  Deputy  Chief  Nurse  has 
  at  ESCC  to  obtain  details of the  changes they have  made  to 
contacted 
enable the Trust to  gain  a full  understanding.  The Trust will then  facilitate the  sharing 
of  that  information  with  the  Trust's  doctors  to  ensure  that  those  who  also  work  as 
independent s.12  doctors,  at the  behest of ESCC,  do  so  in  the  knowledge  of ESCC's 
changes  in  practice. 

Regarding  accessibility  of relevant  patient  clinical  information,  I would  like  to  assure 
you  that  it  has  long  been  the  case  that  ESCC  have  had  access  to  the  Trust's 
electronic  record  system,  Carenotes,  to  enable patient information to  be  accessible to 
them.  The  expectation  is  that  the  ESCC  AMHP  would  access  the  necessary 
information and  appropriately share  it with  any independent s.12  doctor who  does  not 
have  access. 
In  addition,  it  has  been  the  working  practice  for  many  years  that  the 
Trust  also  shares  information  verbally  and/or  by  providing  hard  copies  of  relevant 
patient  records  to  AMHPs  and  to  independent  s.12  doctors,  as  needed.  This  further 
communication  route  facilitates the sharing  of information  if,  for any  reason,  electronic 
access  to  Carenotes  is  not achievable.  The  Crisis  Resolution  Home Treatment Team 
are  the  Trust  team  that  are  available  to  support  the  MHA  Assessors  with  access  to 
relevant patient information and  are available 24  hrs a day.  However,  I recognise your 
concerns  and,  therefore,  have  asked  the  Deputy  Chief  Nurse,  when  she  discusses 
matters  with  ESSC,  to  identify  if  there  are  any  difficulties  with  these  established 
access processes that need to be addressed. 

I hope  that this  Response  is  of  reassurance,  to  both  you  and  Mr  Dixon's  family,  that 
the Trust has  looked  seriously at how it can  support the  MHA Assessment process,  to 
learn from  Mr Dixon's death and to keep  patients safe. 

Your sincerely 

Chief Executive