Following the coroner’s inquest at Manchester Coroner’s Court in October 2014 the senior coroner Nigel Meadows made the following findings and determinations about the death of Eugene St Leger:

Eugene had developed an unrecognised and previously undiagnosed schizophrenic illness. At 5 o’clock on 4 January 2013 he inflicted a serious injury to his neck. When he was discovered by family members he was exhibiting symptoms of mental illness. The ambulance service and police attended and he was taken to Stepping Hill Hospital in Stockport where his injuries were assessed and treated.

He was then transferred to Wythenshawe Hospital at around 8 o’clock where he was seen in the resuscitation area of the Emergency Department and assessed by doctors from the Ear Nose and Throat team. He underwent a CT scan and the decision was made that he did not require surgery until the following morning. In the meantime his wound was dressed and the bleeding from the wound was under control.

A referral was made to the psychiatric liaison SHO doctor but Eugene was not seen and assessed in person by her. By this time he was presenting as being calm, polite, apologetic and cooperative with the treatment. He was not regarded as a high risk patient.

Shortly after 1am the next day he was transferred to a ward and placed in a side room. He was not subject to constant observations. His physical condition was stable and there was no evidence that there was active bleeding from his wound site. His family members were in attendance and were waiting outside the room. Eugene was left alone in the room unsupervised. Within a few minutes he had broken a window and climbed out. He then fell from the first floor to the ground floor outside.

His actions exacerbated and possibly cause new damage to his pre-existing injury and he bled profusely. Initially he was conscious but then went into hypovolaemic shock. This is a life threatening condition in which severe blood and fluid loss make the heart unable to pump an adequate blood supply to the body. It causes multiple organ failure. Eugene went into cardiac arrest and despite efforts to resuscitate him over prolonged period of time he was pronounced dead two hours later.

As part of his narrative conclusion the Coroner found:

His death was contributed to by the combination of the following factors at Wythenshawe Hospital with no one individual alone being responsible:

1. A failure by the treating ENT doctors and the SHO psychiatric liaison doctor to adequately ascertain, record and assess the full clinical significance of all his relevant history obtainable from the available medical records from Stepping Hill Hospital as well as from the police, the ambulance service and the family.

2. A failure to recognise that this was a psychiatric emergency and he was a patient at high risk of further self-harm or seriously abnormal or non-compliant behaviour.

3. The failure by the SHO psychiatric liaison doctor to see and assess him in person or otherwise manage her clinical responsibilities to ensure that he was seen and assessed by a suitably qualified member of the mental health clinical or nursing team.

4. Failure to recognise and ensure that he was subject to constant observations until the assessment could have been completed.

5. A failure by the treating ENT doctors to challenge the SHO psychiatric liaison doctor’s clinical management plan and appropriately escalate it.

Following on from the Coroner’s inquest Eugene St Leger’s family have instructed Victoria Price at Price Slater Gawne to bring a claim against the South Manchester University Hospital Trust for negligence.

Mr St Leger’s family attended the inquest every day and gave evidence about what they had witnessed that night. They have earnestly campaigned for systemic changes at the Trust and, as a result of their efforts and the Trust’s response to these events changes have indeed been made. The family are keen for national recognition of the shortfalls in services for patients with mental health problems and for changes across the board in acute and community services.

In their view Eugene’s death should have been prevented. He didn’t get the help he needed that night. The family members and the emergency staff who had seen Eugene that evening could and would have provided crucial information about his mental health symptoms to the clinical staff but this was not deemed to be as important as the injury to his neck. They believe extent of his mental health problems was overlooked. If the risk had been identified the outcome would have been different.

For more information contact Vicky Price on 0161 615 554 or victoria.price@psg-law.co.uk

http://www.manchestereveningnews.co.uk/news/greater-manchester-news/care-failures-triggered-eugene-st-7956204

http://www.manchestereveningnews.co.uk/news/greater-manchester-news/man-who-fell-death-wythenshawe-7929273