Brothers warned health trust days before man's death

A homeless man died 10 days after his brothers warned a mental health trust that they feared his death unless action was taken to protect him.

Barney Spicer had spent much of his adult life suffering mental illness, and was discharged from a mental health hospital in Shrewsbury in November 2024, with nowhere to live, an inquest heard.

The 45-year-old former chef died on 14 December, after a night out in Ludlow, of combined drug toxicity, bronchopneumonia, fatty liver disease and ischaemic heart disease.

The inquest concluded death by misadventure, and heard that he had taken cocaine and ecstasy.

Heath Westerman, assistant coroner for Shropshire, Telford and Wrekin, ruled his death was not preventable.

Barney was discharged in snowy weather in November 2024, with no permanent address, and for a time slept under the Market Hall in Shrewsbury.

It was a long way from his idyllic childhood, growing up with his brothers Greg and Luke Spicer near Ludlow.

"We did everything together," said his brother, Greg.

Luke said: "We had a great young life, doing things that young lads do in the countryside - playing games, hitting each other with sticks, playing in the garden."

But Barney's mental health deteriorated following the loss of their mother when he was 19.

He had schizoaffective disorder - a mental health condition in which patients experience psychosis as well as mood symptoms - and he was frequently either in hospital or receiving treatment in the community.

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He had attempted to take his own life more than once, Luke said.

Greg added: "I just don't feel there was any care. I feel like he was seen as a problematic individual, and I'd be the first to admit that he could be really challenging - I found him really challenging sometimes.

"But I think by the end of his life the institutions that were supposed to care for him couldn't see past that."

The coroner concluded that Barney had considerable support from his family, adult social services, mental health workers, the rough sleeper team and friends.

But he identified a number of "significant gaps in multi-agency coordination - missed opportunities to work collaboratively to reduce risk".

Barney's brothers disagree with the coroner's ultimate finding, however, that these failures did not contribute to his death.

Greg said he felt that staff working in mental health and support services were usually "really trying to do their best" but often their hands were "tied by a lack of funding, a lack of understanding" and were operating in a system that was "broken".

In an email to the Midlands Partnership University NHS Foundation Trust (MPFT), before his death, Luke said he feared his brother was considered "a lost cause".

He said he could not understand how Barney could go from being sectioned under the mental health act and then moved to two Psychiatric Intensive Care Units outside of Shropshire, before returning to the Redwoods Centre in Shrewsbury and then discharged into the community all in a little over six weeks.

Before Barney's death, the brothers also questioned why at the time of his discharge a Community Treatment Order (CTO) was not in place - a legally binding agreement that details what behaviour is expected of him and what treatment would be provided in the community.

Crucially, the family also said it would make it easier to recall him to hospital.

However, the inquest heard that previous CTOs had not worked and that they depended on Barney voluntarily accepting injections of his medication and other help.

He was a different person on medication.

The family explained that when he did not have his injections he could be violent towards himself and others.

Luke said: "When he was poorly he could be a little bit scary, anyone with that kind of illness can come across like that.

"But essentially he was a man who had spent most of his adult life in and out of care, had been supported a lot more in his early years and as he got sicker the support seemed to drop over time and I don't think he fully knew how to look after himself properly."

The coroner concluded the decision not to put a CTO in place was appropriate, and the inquest heard there were other mechanisms to recall Barney to hospital if needed, although the family claim that the CTO would have offered the swiftest route.

Greg and Luke's main dispute, beyond the decision not to issue a CTO, was over Barney's capacity to make decisions that affected his life.

The inquest heard medical professionals at the Redwoods Centre and in the community believed he had the capacity.

However, the brothers disputed that and said he had been in and out of hospital, not realising how much he depended on the support of others, nor knowing how to effectively access that support.

In an email, Greg said he felt the NHS trust was effectively saying that Barney's bad decisions, such as taking drugs, were his to make.

Barney had refused medication injections at times earlier in the year and following his discharge, refused again on 11 December.

He had previously been removed from accommodation in August 2024, the inquest heard, due to his behaviour - a decision that the coroner found to be appropriate.

And had refused other accommodation.

After his discharge, Barney continued to have contact with his key worker and a mental health nurse, who both encouraged him to apply for housing, the inquest heard - although the nurse said she felt he had a lack of understanding of the process, despite efforts to explain it to him.

"In my opinion, and in my brother's opinion, Barney wasn't capable of making those applications by himself," Greg said.

"He really felt he should just be housed... he never really understood why his problems were just not being sorted out for him.

"You have to remember that this is a man who spent the vast majority of his adult life in institutions where people did things for you."

In concluding the inquest, the coroner said he found that Barney had capacity to make decisions and that even if he had accepted his medication and had been provided with suitable accommodation, there was nothing to prevent him travelling to Ludlow to stay with friends.

Westerman added that Barney's decision to consume "excessive amounts of cocaine and ecstasy" had an "unintended consequence and that misfortune intervened and sadly took his life".

In response, MPFT chief executive Neil Carr, who offered his condolences, said the trust had carried out a "robust multi-agency review" into the care Barney received.

"This review involved all colleagues involved in Barney's care and considers the care and treatment provided from the point of admission to the events after his discharge from the Redwoods Centre in November 2024, which sadly led to his death.

"A full copy of this review and its findings was shared with the family, and the trust remains open to further contact with the family.

"Furthermore, the trust is committed to working with partners to jointly develop an action plan addressing recommendations from the recently published multi-agency review into Barney's death."

Shropshire Council said it had "fully participated in and assisted the coroner's inquest" and said it felt that it was important to "carefully consider the coroner's findings before commenting any further".

"We remain committed to learning and to continually improving the services and support we provide," it added.

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