'Failure to monitor' psychiatric patient's killer

The death of a psychiatric patient, who was killed in a secure mental health unit, could not have been prevented by medical staff but there was a "failure to monitor" his killer, an inquest has found.

Fellow patient Ahsan Zia, 33, punched, kicked and stamped on Michael Matthews, 55, at Hadrian Clinic in Newcastle on 13 April 2022.

Matthews suffered extensive head and facial injuries in the 28 second attack in his room on the acute Fellside wing and went into cardiac arrest. He died in Newcastle's Royal Victoria Infirmary four days later.

Cumbria, Northumbria, Tyne and Wear NHS Foundation Trust told the inquest changes to working practices have been made in light of the incident.

The inquest into his death at Newcastle Coroner's Court previously heard that a Prevention of Violence and Aggression Plan (PMVA) had not been drawn up for Zia because he did not present as violent when he was admitted to the Hadrian Clinic.

Giving her conclusions, senior coroner Georgina Nolan said Zia was "dependant" on antipsychotic drugs and was being treated in the community, but in the previous July he had asked his doctors to reduce one of his medications, which they did.

Zia had no contact with his psychiatrists for almost five months and despite requesting a further medication review he was "not seen".

The coroner said in the months leading up to the incident there "was a failure to monitor him more closely" and his "drastic deterioration in mental health in the community was allowed to go unmonitored".

Zia, who suffered with delusions about a plot to rape and kill Matthews, was put on an "observation regime" at the Hadrian Clinic.

The coroner concluded that "further assessment" would not have prevented the attack, and whilst Zia should have been put on a PMVA given his previous history, the lack of this "did not contribute" to Matthews' death.

In August 2023 Zia was given an indefinite hospital order by Newcastle Crown Court after denying murder but admitting manslaughter by reason of diminished responsibility. He is being treated at the maximum security Rampton Hospital.

In a statement, Matthews' brother Martin Matthews described him as "a very much loved son, brother and uncle."

"We as a family will never know the real reason behind the brutal attack on Michael. But we will have to live with the aftermath of these terrible events for the rest of our lives

"We as a family will never make new memories with Michael due to the actions of one person."

Rajesh Nadkarni, Deputy Chief Executive and Medical Director at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust said they would "carefully consider the conclusions drawn by the coroner."

"Our thoughts are with Michael's family and everyone who knew and cared for him at this difficult time.

"Since Michael's death, we have made important changes. We have strengthened how staff assess and manage risk, plan care, keep records and share information. We have also improved checks on staffing levels and the way concerns are raised when more staff are needed.

"We have increased access to senior clinical staff across all seven days. We have also reviewed arrangements for patients who have agreed leave from hospital and improved how we respond to serious incidents.

"We are committed to learning and improving so we provide safe, compassionate care that every person deserves."

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