Mental health patient died days after hospital discharge

Carrow House, where Norfolk Coroners Court is held. Picture: ANTONY KELLY

An inquest has been held into the death of Michael Wheeler of York Road, Great Yarmouth. - Credit: Archant

A mental health patient with a long history of drug abuse died days after being discharged from hospital to the home of another known addict.

Michael Wheeler was found dead on his friend's sofa despite concerns from his family that he was not ready to leave the ward at Northgate Hospital in Great Yarmouth and that no suitable accommodation had been secured.

East Coast Community Healthcare. Team meeting at the Northgate Hospital site.
Picture: James Bass

Michael Wheeler was an in patient at Northgate Hospital during the pandemic. He died three days after he was discharged. - Credit: Eastern Daily Press © 2015

Norwich Coroner's Court heard the 36-year-old paranoid schizophrenic had been detained under the mental health act in April at the height of the pandemic after being found "shouting and screaming" in Great Yarmouth.

Four months later he was discharged to the home of a fellow drug user after all other housing services and hostels refused to take him.

He died three days later. The cause of death was given as multiple drug toxicity.


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Giving evidence Dr Larry Ayuba said everything possible had been done to find supported housing for Mr Wheeler who was a facing prosecution for arson.

The psychiatrist said after four months in hospital Mr Wheeler's mental health improved to the point he was being considered for discharge.

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However, the inquest heard he had been evicted by Great Yarmouth Borough Council for starting a fire in his flat and was adamant he wanted to carry on drug taking.

Because of his complex needs all referrals for housing were rejected.

In the end, and at Mr Wheeler's insistence, he was discharged to the flat in York Road where he died on July 24, 2020.

Senior coroner Jacqueline Lake asked Dr Ayuba  if enough had been done to find Mr Wheeler a safe place to live and if he could have been detained in hospital any longer.

Jacqueline Lake, senior coroner for Norfolk

Senior coroner Jacqueline Lake recorded a verdict of drug related death for Michael Wheeler. - Credit: Simon Finlay

He said  because Mr Wheeler was deemed medically fit there was nothing more they could do to hold him and that all other avenues had been exhausted.

He said: "The major issue with Michael was that he was insistent that he was still going to go back to his friends so he could continue to take his illicit substances.

"We thought Herring House would take him but the fire risk probably put them off. He insisted he was going to his friends.

"We had no choice at that point. We simply could not hold him in hospital.

Community mental health nurse Barry Bailey said he felt the discharge to his friend's house in York Road was "unsafe".

"We knew he was well enough to come off the ward but where he was going was unsafe," he said. "But there were no other options. We had tried everywhere."

Social worker Wiebke Behrens said: "We were really, really stuck.

"It was not a good discharge, it was not a safe discharge. There were no options."

Both professionals highlighted the lack of drug and alcohol rehabilitation services which may have been beneficial.

The inquest also heard steps were being taken to address the housing gap for people like Mr Wheeler who had complex needs.

Sixty new flats and bedsits were being developed over the next three years for people that were rejected by other providers.

NSFT (Norfolk and Suffolk Foundation Trust) had also held its own serious incident review which lead to a number of changes including the creation of a complex case pathway allowing for "fresh eyes" and input in difficult cases where there were no obvious solutions.

Mrs Lake said she was heartened the issues had been taken seriously.

During the inquest Mr Wheeler's brother John expressed frustration there was no supported living for his brother who ended up staying with someone else that was vulnerable.

However he also expressed relief there would likely be more help in the future.

Mrs Lake  recorded  a verdict of drug related death.

She said  she was satisfied steps were being taken to address some of the concerns raised at the inquest around the difficulties of placing people like Mr Wheeler with complex needs and stopped  short of issuing a prevention of future deaths report.

His sister Jenny said he was a "very kind and quiet man" who had struggled with his mental health since he was a teen.










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