Vincenzo Lippolis

NAViGO 

IN  THE  MATTER OF THE INQUEST IN  TO THE  DEATH OF VINCENZO JOSEPH 

MICHAEL LIPPOLIS 

RESPONSE OF NAVIGO TO THE PFD DATED 26/10/2022 

FROM MR PAUL COOPER, HM ASSISTANT CORONER FOR LINCOLNSHIRE 

Introduction 

1 

This is the response of NAVi GO to the Regulation 28:  Report to Prevent Future Deaths 

(the  Report) raised  by Mr Paul  Cooper,  HM  Assistant Coroner for Lincolnshire,  dated 

26  October 2022,  following  the  conclusion  of an  inquest on  26  October 2022  into the 

death  of Vincenzo  Joseph  Michael  Lippolis,  who  died  on  1 November 2021  when  he 

was found  hanging in a woodland  by his shoelaces. 

2 

NAViGO  Health  and  Social  Care  CIC  (Community Interest Company)  provides  NHS 

commissioned adult mental  health services in  North  East Lincolnshire. 

Organisations named in  the Report 

3 

Two  organisations  are  named  in  the  Report  and  it  will  be  helpful  in  reading  this 

response to  understand the  involvement of each: 

3.1 

NAViGO provides psychiatric liaison services at the Diana Princess of Wales Hospital, 

Grimsby  (the  Hospital).  On  16  October  2021  Vincenzo  Joseph  Michael  Lippolis 

attended  the  Emergency  Department  at  the  Hospital  after  .an  attempt  at  hanging 

himself.  When  medically  fit  he  was  referred  by  the  Emergency  Department  for 

assessment  by  the  Hospital  Liaison  Psychiatric  Team.  This  was  NAViGO's  only 

involvement with  Vincenzo Joseph  Michael  Lippolis. 

3.2 

Lincolnshire  Partnership  NHS  Foundation  Trust (LPFT)  is  an  NHS  Foundation  Trust 

providing  adult  mental  health  services  in  Lincolnshire  but  outside  the  area  of  North 

East  Lincolnshire  covered  by  NAViGO.  Vincenzo  Joseph  Michael  Lippolis  lived  in 

Mablethorpe,  Lincolnshire,  which  is  part  of  the  area  covered  by  LPFT  services. 

NAViGO  is  not aware  of the  full  extent to  which  LPFT  has  previous,  or subsequent, 

involvement with  Vincenzo Joseph  Michael  Lippolis. 

1 

 Issues raised by the Coroner 

4 

The Report raises two  matters of concern,  in  summary: 

4.1 

That Vincenzo Joseph Michael Lippolis was not sectioned under the Mental Health Act 

1983 following  assessment by the  Hospital  Liaison  Psychiatric Team  on  16  October 

2021;and 

4.2 

That  LPFT  had  telephone  contact  with  Vincenzo  Joseph  Michael  Lippolis  on  17 

October 2021  rather than face to face contact and  more effective analysis. 

5 

6 

This response only responds to  the first concern relating to  NAViGO's involvement. 

The only observation  made on  the second  concern  is that NAViGO's Hospital  Liaison 

Psychiatric Team  contacted  the  relevant  LPFT services  after the  assessment at the 

Hospital and requested a face to face follow-up with Vincenzo Joseph Michael Lippolis 

by his local services (as detailed  in the written report of 

,  NAViGO Liaison 

Practitioner,  dated 22 October 2022, provided to  the Coroner). 

The Concern in  relation to NAViGO 

7 

The concern as set out in  the  Report is: 

"In  the  NAVIGO  report of 22nd  October 2022  in  response to  the  mother's  request  as 

to  "why Vincenzo  wasn't sectioned  under the  Mental  Health  Act after his  detrimental 

(suicide) attempt on  16th October if only for observation" the SW replies "An admission 

to  a  mental  health  u·nit  wo'u[d  not  provide  a  therapeutic  benefit  as  Vinny's  social 

stressors  would  still  be  present  in  the  future".  The  response  does  not  seem  to 

consider/reflect the admission criteria  under s.2 or s.3 of the  MHA. 

Please  clarify  the  rational  as  the  family  believe  an  opportunity  has  been  lost  and  a 

death could  have been averted ." 

Response to the Concern 

8 

9 

The response falls  in  two parts: 

First, the appropriateness of raising the concern in  the report: 

9.1 

It  is  suggested  that  it  would  have  been  more  appropriate  for  these  matters  to  have 

been dealt with  in  the inquest. 

9.2 

It is noted from the timeline in section 4 of the Report that comments from 

were only requested on  14 October 2022. Her comments were provided on 22 October 

2022. 

  was  not asked  to attend the  inquest and  it is  noted  in  the timeline 

on  24 October 2022 that "Comms with  Mum  - discussed the  clinical  notes from 

  - content  that  this  answers  her question".  That  may well  be  the  reason 

2 

 
 
 
 9.3 

However,  it  is  clear from  the  report  that  questions  did  remain  at the  inquest  itself.  In 

fact, the Report appears to be seeking additional evidence, or clarification of evidence, 

on the circumstances around the Deceased's death, specifically the assessment on  16 

October 2021,  rather than  raising  concerns about potentially on-going issues. 

9.4 

It would,  it is suggested, have been more appropriate to have adjourned the inquest at 

that point to  hear evidence  directly from 

  with  NAViGO as  an  Interested 

Person  under s47(f) Coroners and  Justice Act 2009. 

1 O 

Secondly, observations in relation to the concern raised: 

10.1 

The  provision  of a Hospital  Liaison  Psychiatric Team  for initial  assessment of people 

attending an Emergency Department, where a mental disorder is suspected,  is entirely 

consistent with  nationally recognised  practice. 

10.2  Following  assessment there  may be  further actions from  arranging  further support in 

the  community to arranging  additional assessment for possible admission to  a mental 

health  hospital,  either  informally with  the  patient's  agreement  or  compulsorily  under 

the  Mental  health Act 1983 (the MHA). 

10.3  Mr  Lippolis was  assessed  by two experienced  practitioners,  one a Social Worker and 

one a registered  Mental  Health  Nurse. This,  again,  is consistent with good practice. 

10.4  Those  practitioners  could  not,  themselves  have  made  an  application  for  detention 

under  the  MHA.  That  would  require  assessment  by  two  doctors  and  an  Approved 

Mental  Health  Practitioner.  Of the  two  doctors  at  least one  must  be  approved  under 

s12  MHA,  as  having- special  experience  in  the  diagnosis  or  treatment  of  mental 

disorder,  and  at  least one  should, if practicable,  have previous acquaintance with the 

patient. 

10.5  However,  the  Liaison  Team  practitioners,  were  experienced  in  assessing for signs of 

mental  disorder  and  -would  have  had  the  criteria  of  the  MHA  in  mind  during  the 

assessment. 

10.6  Relevant elements of the MHA in this case are: 

10.6.1  Section  1 (3)  specifically  excludes  dependence  on  alcohol  or  drugs  as  a 

disorder or disability of the  mind for the purposes of the  MHA. 

10.6.2  Section  2  allows  for the  compulsory  admission  of a  person  for  assessment 

(and treatment) if he is suffering from  a mental disorder of a nature or degree 

which  warrants detention for at least a limited  period  AND  he  ought to  be  so 

detained  in  the  interests  of  his  own  health  or  safety  or  with  a  view  to  the 

protection of other persons. 

3 

 10.6.3  Section 3 would  normally only be considered after use of section 2 unless the 

• ' 

person  was  already well  known  to  services  and  had  a  diagnosis  of mental 

disorder.  It  allows  compulsory  admission  to  hospital  for  treatment  and  has 

stricter  criteria  for  admission  including  that  it  is  necessary  that  the  patient 

receive treatment and  it cannot be  provided  unless the patient is detained. 

10. 7 

It is  also  relevant to  consider the  Code  of Practice to  the  MHA,  which  gives  statutory 

guidance to  practitioners.  Practitioners must have regard  to the  Code of Practice and 

follow  it  unless  they  have  good  reasons  not to  (see  the  Introduction  to  the  Code  of 

Practice paragraphs I to V). 

10.8  Chapter 1 of the  Code of Practice sets out a number of principles to  be  followed.  The 

first  is  "Least  restrictive  option  and  maximising  independence".  Paragraph  1.2  states 

"Where it is possible to treat a patient safely and lawfully without detaining them  under 

the (MHA),  the patient should  not be detained". 

10.9  As  set  out  in  the  written  comments  of 

  dated  22  October  2021  the 

assessment found : 

10.9.1  The  risk  of suicide  was  significantly  increased  whilst  Mr  Lippolis  was  under 

the  influence of cocaine and alcohol. 

10.9.2  At the time of assessment he was not under the influence of drugs or alcohol 

and  he  denied any suicidal thoughts, plans or intent to  end  his life. 

10.9.3  There was  no  evidence of acute mental illness. 

10.9.4  The  suicide  attempt  resulting  in  the  Emergency  Department  admission 

appeared  to  be  directly linked  to  a relationship  breakdown  and  alcohol  and 

cocaine misuse. 

10.9.5  Mr Lippolis regretted  his actions and was keen to engage with the local LPFT 

crisis team  and  his local drug and  alcohol  services. 

10.9.6  He  spoke fondly of his work and family being  protective factors . 

10.9. 7  Mr  Lippolis  appeared  to  understand  that  substance  misuse  increased  his 

impulsivity and therefore was happy to work with services to address this and 

decrease the risk of a further suicide attempt. 

10.1 O  The  rationale  for referral  back to  local  LPFT services and  not further assessment for 

admission was therefore that: 

10.10.1  Admission under the MHA cannot be justified on safety grounds alone. There 

must be an element of mental disorder at least warranting assessment. 

4 

 10.10.2  Mr Lippolis  did  not appear to  be  suffering from  a mental  disorder at the time 

of assessment. 

10.10.3  His  primary  triggers  for  self-harming  behaviours  were  drug  and  alcohol 

misuse, which are not issues that can be used to justify compulsory admission 

under the MHA in  the absence of a mental disorder. 

10.10.4  He was  willing  to  engage with  local  services  so  support and  treatment could 

be provided outside hospital, and were more appropriate for provision outside 

hospital. 

 comment that "an  admission  to  a mental  health  unit 

would  not provide a therapeutic benefit as Vinny's social stressors would  still 

be  present  in  the  future", reflects  the  fact that an  admission  would  not have 

made  the  destabilising  factors  disappear.  It  was  more  appropriate  for  Mr 

Lippolis to  engage with  the issues in  the community. 

10.10.5  There  was  no  indication  that  he  would  further self-harm  at that time  and  he 

did  not,  in  fact,  do  so.  There  is  a  period  of  15  clear  days  between  the 

assessment on  16 October 2021  and  his tragic death on  1 November 2021. 

10.10.6  The  decision  not  to  admit  Mr  Lippolis  but  to  refer  him  to  local  services  for 

follow-up was agreed by him and entirely consistent with the principle of least 

restriction  and  maximising independence. 

10.10. 7  Given his presentation at assessment and immediately afterwards it would be 

·entirely speculative: to suggest that a very short admission, with no symptoms 

of acute  mental · disorder,  would  have  prevented  whatever  triggered · his 

actions on  1 November 2021 . 

10.10.8  The  referral  to  local,  LPFT,  services  was  made with  a  recommendation  for 

face to face follow-up,  consistent with good  practice . 

Action proposed by NAViGO in  response to the concern 

11 

NAViGO does not propose to take any action in  relation to its systems or processes in 

response  to  the  concern  raised.  The  response  above  sets  out  the  rationale  for  the 

decision.  It  followed  an  assessment  of Mr  Lippolis  in  line  with  nationally recognised 

practice  by  two  experienced  practitioners.  The  decision  was  based  on  Mr  Lippolis' 

responses  and  presentation  at  the  time  and  the  professional  judgement  of  the 

practitioners. For the reasons given above there is,  in NAViGO's judgement, no change 

to  systems  or  processes  that  need  be  made  in  order  to  avoid  deaths  in  future. 

Decisions  will  always  depend  on  the  particular  circumstances  of  each  individual 

assessment. 

12 

It is  hoped the response assists the family in  understanding the process and  rationale 

for the decision on  16 October 2021. 

5 

 13 

NAViGO regrets that it did not have the opportunity to provide that information, through 

its staff, at the inquest. 

14 

If the family have any further questions NAViGO would  be happy to receive them from 

the family and  will  respond  directly to  the family. Any further questions can  be  raised 

by contacting : 

Patient Advice and  Liaison Service 

NAViGO  House 

3-7 Brighowgate 

Grimsby 

North East Lincolnshire 

DN32 0QE 

Position  Chief Executive 

Dated  4.1.2023 

3016 

43805/60 

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