NHS Trust criticised over mental patient death

An inquest jury at Hove Crown Court has reached a verdict of ‘death from hanging whilst suffering a mental health illness’ in the disturbing case of a Brighton man found dead at his home. Rachel Heelis of Attwaters Jameson Hill Solicitors acted on behalf of the deceased’s identical twin brother at the inquest, which lasted 2½ weeks.

An inquest jury at Hove Crown Court has reached a verdict of ‘death from hanging whilst suffering a mental health illness’ in the disturbing case of a Brighton man found dead at his home. Rachel Heelis of Attwaters Jameson Hill Solicitors acted on behalf of the deceased’s identical twin brother at the inquest, which lasted 2½ weeks.

Patrick Whiting, who had previously attempted suicide, died at home a few days after being discharged from a mental health unit. He suffered from known mental health problems, including anxiety, delusions and psychotic depression. In March 2012, he had attempted to take his own life by plunging 30 metres onto electrified railway tracks near his home.

He survived the fall and was admitted to hospital with spinal fractures and bruising. During his time at the hospital, Patrick gave a suicide note to his twin brother Andrew who passed it to staff. A copy of the suicide note wasn’t kept with his medical notes. Having been ‘sectioned’ under the Mental Health Act, he was later transferred to a secure unit run by Sussex Partnership NHS Foundation Trust at Conquest Hospital, St Leonards.

In May 2012, following a relatively short period of acute care, Mr Whiting was deemed to be in a sufficiently stable mental state to be released from the unit, which was experiencing a beds shortage at the time. He was sent back to his own home.

Arrangements were made for daily support from Brighton Crisis Resolution and Home Treatment Team, an alternative to hospitalisation whose core interventions include relapse prevention and identification of triggers. Three days after he was returned to his home, his twin brother found him hanging in his bedroom.

“The inquest heard about a number of disturbing aspects to this tragic case, which had led the NHS Trust concerned to issue an apology to Patrick Whiting’s family,” comments Rachel Heelis. “Patrick’s brother Andrew, my client, had previously worked as a mental health nurse with the Sussex Partnership Trust and acted as his carer, yet he was neither consulted nor informed about his twin’s progress in the weeks before his death.

“We found that managers had made decisions to alter this vulnerable patient’s treatment without consulting clinicians and called him to a meeting about this without telling his treatment team. His original care plan involved graded leave prior to discharge, but he was returned to his flat without having set foot outside the ward. Staff also failed to note the deterioration in his mental health at the prospect of going home.

“Ambiguity surrounded whether Patrick Whiting was on leave or being discharged. Either way, the home treatment team had grave concerns that he had left hospital too soon. His long-term mental health medication had been changed, but staff had not properly monitored its effectiveness, nor had adequate account been taken of a suicide note written by the patient when first admitted, nor of a shoelace found around his neck the day before discharge.”

The inquest was told that, as Patrick Whiting’s carer, his brother Andrew was given no copy of his treatment plan or care plan and that the patient was sent home without his medication. His flat was said to be in a state of disrepair, aggravating his fear of going back there. The morning prior to his death, he had shown the home treatment team a noose he had made with a black dressing gown cord, this was the same noose he would use to hang himself hours later. The nurses failed to confiscate it or arrange for his readmission to hospital, or even tell his brother, who was in the house during the visit, of the incident.

“Andrew found Patrick hanging the following morning and it has since been established that the same dressing gown cord had been used,” Rachel Heelis adds. “This tragedy for Patrick has also been an appalling ordeal for Andrew. It is right that the NHS Trust has acknowledged significant failings and is at last making appropriate changes, though sadly too late for Patrick.

“This was a lengthy and complex inquest and I should like to pay tribute to the jury, who had to consider various issues of fact, law and medical evidence. After deliberating for 1½ days, their unanimous verdict that Patrick Whiting died from hanging whilst suffering a mental health illness included a conclusion that ‘his mental health had been deteriorating for a number of weeks and this was not sufficiently recognised by staff and his risk was not adequately managed’.”

The jury’s verdict reflected acceptance that Patrick Whiting’s discharge from acute psychiatric hospital was premature and carried out in a confused manner. This resulted in him having an unclear leave plan, of which individuals had differing understandings, and incorrect quantities of medication. The care plan identified Patrick Whiting as high risk and having a low threshold for readmission to hospital. An obvious deterioration in his mental health was not acted upon and he should have been immediately readmitted.

“Various issues contributed to Patrick Whiting’s deteriorating mental health and untimely death,” Rachel Heelis summarises. “These included a catalogue of failings related to an inadequate care plan, lack of communication, administrative shortcomings and poor monitoring of medication and other influences upon his mental state. Lessons must be learned from this and the Coroner confirmed at the close of the inquest that she will be sending the Secretary of State for Health a ‘Rule 43 Report’ about her concerns on a national level to help prevent further deaths occurring.”