Inquest finds “serious failings” at NHS Trust

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An inquest found this week “serious failings” at Surrey and Borders NHS Trust that led to the death of a man by suicide following his admission to an acute mental health ward in May 2020.

Novum Law’s specialist inquest lawyer, Mary Smith from our Bristol office, assisted by Rebecca Brisley, represented the man’s family (referred to as ‘AZ’ to protect his identity).

On 8 May 2020, AZ was admitted to the acute mental health ward, run by Surrey and Borders Partnership NHS Foundation Trust. He was experiencing low mood, suicidal thoughts, depression, and insomnia. He also had a recent history of self-harm.

A few hours before his admission, he had been assessed as “high risk” by a psychiatric liaison team led by a Consultant Psychiatrist at a different hospital.

Serious failings at acute mental health ward

On his arrival at the hospital, he had two bags. However, despite the hospital’s policy, neither AZ nor his two bags were searched to ensure any items that could be used as a ligature were removed and stored safely.

A junior psychiatrist saw AZ when he was admitted and decided to downgrade the risk to himself to ‘medium’. AZ was supposed to be monitored every 15 minutes by staff; however, they failed to do this and did not adequately engage with him or observe him – despite his subdued manner on the morning of his death.

At about 1 pm on 9 May 2020 (about 36 hours after admission), a staff member found AZ hanging in his dormitory bathroom from a ligature he had made from two shoelaces.

During the inquest, the Jury heard evidence that a similar death using the same ligature point (a door hinge) had happened just a few weeks before AZ’s suicide.  Despite this, the staff took no steps to remove or make safe the ligature point used.

The Jury found that the Trust should have identified and removed the hinge to the dormitory bathroom because it posed a “significant risk” to patients.  The Jury also found that the failure to do an adequate search of AZ and his belongings “represented a missed opportunity to identify potential ligatures in his possession and to engage with AZ in the process.”

The Jury ruled the Trust’s assessment of AZ’s welfare needs and the care plans in place for him as “inadequate”. Furthermore, the hospital team carried out supportive observations with “inadequate engagement, recording and reporting”.

Mary Smith, who acted on behalf of AZ’s family in relation to the inquest, said:

“Our hearts are with AZ’s family at this difficult time. This is a tragic case where a man lost his life due to serious failings by an acute mental health ward with a duty of care who should have ensured his safety.  Making sure hospital wards are free of potential ligature points and that mental health patients do not have access to items that can be used as ligatures is a fundamental requirement.  Deaths like AZ’s are avoidable, with adequate risk assessments, policies, and processes followed by psychiatric and nursing staff.  Our sincere hope is that the Trust has learned lessons and that in the future, tragedies like this are avoided.”

Rebecca Brisley, from Novum Law’s Plymouth office, who has been supporting AZ’s family throughout the inquest process, added:

“Having spent the week supporting and advising AZ’s family during the inquest, I was incredibly saddened to learn of the multitude of failings in care but was humbled by their quiet strength and resilience during this tragic time.

“Listening to evidence which built an ever-increasing picture of missed opportunities to provide life-saving care was deeply upsetting, and my thoughts remain with his family as they try to navigate their way through the darkest of times.  We cannot turn back the clock, but we can hope that in highlighting these failures, other families will not be devastated in this way in the future.”

Novum Law instructed the specialist Barrister Frederick Powell of Doughty Street Chambers to act for the family at the inquest.

Our inquest team regularly represents families at inquests providing expert advice and support throughout what can be an overwhelming and challenging process. Click here to find out more about our inquest services. Alternatively, please call our specialist inquest team on Freephone 0800 884 0777 or contact us online for a free, no-obligation chat.

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