Failings at mental health unit cost man’s life

  • January 4, 2019
  • Steve, a talented artist, tried several times to kill himself while hallucinating during a mental health crisis – he had warned staff at the unit where police had taken him that he would do so, and attempted suicide, yet staff still left him unobserved. After he self-harmed so severely that he later died, his mother came to Peter Savage at Medical Accident Group to seek justice for her son.

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    Never having suffered from mental health problems before, Steve was taken by police to the mental health unit of the local hospital when he was found distressed, and convinced that he was going to hell.

    The police stayed with him at the unit for two hours before he was admitted – his behaviour worsened in that time, as he had hallucinations and stated that he needed to kill himself to avoid going to hell. He was kept under constant observation while they waited, including when he went to the toilet.

    A ‘place of safety?’

    The police were then told that he could be left in the care of the unit – he was admitted to a room near the nurses’ station and assessed as needing checks every 10 minutes. Five minutes after admission, he asked for paper and pen which he was given. Five minutes later, after hearing a noise, a member of staff went into his room to find him lying on the toilet floor, having cut his neck on the broken pen.

    He was then seen to take the laces from his shoes and he told staff he wanted to die. His laces were taken away and the staff closed his bedroom door, leaving him unobserved.

    Intensive care for cardiac arrest

    Ten minutes later, he was found choking – he collapsed and staff could not find his pulse. He had stuffed the paper into his mouth and was rushed to intensive care. He died 11 days later after his life support was removed – he had suffered cardiac arrest, oxygen deprivation and brain damage.

    Peter said: “If he had been properly assessed at any stage, if he had been observed constantly as he was by the police while they waited with him, his death could have been prevented. The staff knew he was suicidal and they knew that he had tried to kill himself in the short time between his admission and his final attempt.

    “It is almost incredible that after he had cut his neck with the pen, taken out his shoelaces and talked about killing himself that no-one thought it important to observe him fully and make sure that he had no way of harming himself further.

    Care failures led to apology

    “No amount of money could ever mitigate such a loss, but I was glad that I was able to obtain a full written apology from the Trust’s chief executive for his mother, with £16,000 compensation. We pursued this claim under the Human Rights Act and his mother and sisters plan to use the damages to fund a lasting tribute to him.”

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