A dad banned from leaving a South London hospital alone slipped out and took his own life due to communication failures by nursing and medical staff, a coroner has found. The 44-year-old, who we have decide not to name, died from multiple traumatic injuries after entering a railway track while on unescorted leave from Springfield Hospital in the middle of a mental health crisis in 2022.
HM Assistant Coroner for Inner West London Paul Rodgers found an inadequate handover, a failure to understand his suicide risk, and mistaken permission to leave the hospital alone contributed to the man’s death.
“There were repeated failures by nursing and medical staff to read, understand and replicate plans around safety off the ward or unit, which erroneously led to [the man] being permitted leave when he should not have been,” wrote Mr Rodgers.
“Part of the reason for this was a lack of joined up policy and risk management around how safety on leaving the unit or ward was being assessed in the case of voluntary patients creating ambiguity, according to the [root cause analysis] review.”
An inquest held last week heard the man became depressed after a Covid infection. A GP prescribed him anti-depressants and he tried talking therapy, but his depression worsened he eventually tied a ligature and travelled out of London intending to take his own life, the inquest heard. After speaking to a police officer and mental health nurse he decided to come home.
When he returned to London, the man was assessed as a high-risk of suicide at Springfield Hospital’s Coral Unit, but, according to the coroner, he waited longer than he should have to be admitted to a psychiatric ward due to an inpatient bed shortage. During that time a plan was drawn up that required him to be escorted if he wanted to leave the hospital.
But during the handover from the Lotus Unit to Ward 2, the escort plan was not properly communicated and there were issues with note taking. This meant staff on Ward 2 did not understand the plan, nor the man’s suicide risk. Tragically the man entered a staff only stairwell through an unlocked door and left the grounds through a swipe operated staff door, taking his own life a short while later.
“[The man] should not have been granted unescorted leave from the Ward on the occasions this was granted and that had [the man] not been granted unescorted leave on that day his tragic suicide would likely have been prevented,” concluded Mr Rodgers.
In his PFD, Mr Rodgers said he remains concerned that safety planning around leaving and going off the ward as a voluntary patient ‘has not been given the prominence it requires’, like in the mans case where his plan was not identified by staff effectively.
You don’t have to suffer in silence if you’re struggling with your mental health. Here are some groups you can contact when you need help.
Samaritans: Phone 116 123, 24 hours a day, or email [email protected] in confidence
Childline: Phone 0800 1111. Calls are free and won’t show up on your bill
PAPYRUS: For teens and young adults. Phone 0800 068 4141
Depression Alliance: The charity offers useful resources for people struggling.
Students Against Depression: For students who are depressed, have low mood, or are suicidal.
Campaign Against Living Miserably (CALM): Phone 0800 58 58 58. For young men who are feeling unhappy.
James’ Place: Offering life-saving treatment to suicidal men in London and surrounding area.
For information on your local NHS urgent mental health helpline, visit here
‘We take our patients’ safety extremely seriously’
Springfield Hospital has previously drawn the attention of London coroners due to care failings.
After the death of Michael Hindes in 2023, Coroner Mary Hassell wrote to South West London and St George’s Mental Health NHS Trust, warning ‘lessons are not being learned’ when it comes to mental health services connecting patients with their families.
Michael took his own life after telling staff he had been walking back and forth at the railway station. After a 30-minute mental health assessment, he was sent home without a referral to the crisis team.
Juan David Martin also died while under the care of the Trust, falling from height during a fire alarm while he was waiting for a bed on a secure ward. That time the coroner warned of a ‘genuine risk of future deaths directly connected to a shortage of mental health bed spaces in London’.
Last year an inquest found granting unescorted leave to Paul Davis materially contributed to his death in 2018.
A spokesperson for South West London and St George’s Mental Health NHS Trust said: “We are deeply sorry that the care we provided [the man] was not of the standard it should have been. The Trust is working to better ensure the safety of voluntary patients who are not detained under the Mental Health Act.
“We take our patients’ safety extremely seriously and we recognise there is more to do. We are already working through the Coroner’s feedback and will respond in full to further address each of the areas highlighted. Our thoughts are with [the man’s] family and loved ones.”
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