An inquest began in Carlisle this week into the death of a mental health patient, who was killed when hit by a lorry on the A6. At the time of the accident he was on unescorted leave from the Carleton Clinic, part of the Cumbria Partnership NHS Foundation Trust.
The patient had been admitted to the unit in January 2013, suffering from delusions, paranoia, anxiety and with a history of self harm and attempting to take his own life. He had been sectioned under the Mental Health Act and admitted to the unit for his own safety.
His medication was reviewed and changed on admission. The Trust says that as his condition improved over the weeks, he was given permission to go out into the grounds of the unit alone. At the time that these decisions on leave were being made, the patient’s family asked medical staff not to allow him to go out on his own, as they feared he may harm himself, as he had done so previously. His family were not convinced that he was not stable or safe enough to be left alone.
The inquest heard conflicting evidence about how ward staff notified each other about which patients were off the ward, their whereabouts and when they left and were due to return. The process for knowing which patients were on leave from the ward and when they were due back was not understood or adhered to by all the staff either. Allegedly there was insufficient nursing cover to ensure that nurses could escort those patients on leave from the ward. Some patients were allowed to leave the grounds around the unit and walk out of the hospital.
Despite being sectioned for his own safety and/or the safety of others this patient appears to have left the ward at around 2pm. His leave was until 2.30pm. Evidence suggests that he may have walked out of the grounds sometime around 2.26pm, or possibly 2.21pm. He walked onto the A6 and was hit by the lorry at around 2.46pm.
No one from the ward went to find him at 2.30pm, when his leave ended, or in the hours later. The alarm was not raised on the ward that he was missing until 5pm, and by that time the Police had arrived at the hospital.
The patient was transferred to the Royal Victoria Infirmary in Newcastle, but died a few days later.
The patient’s family believe that they should have been listened to more about the leave arrangements and that they should have been told that he was going out alone. They would have objected to this unless it was for a short time and that staff were with him. If they had known that he could have gone out of the grounds they would have arranged for a family member to have been there with him. They are also unhappy that none of the staff knew where he was nor were they monitoring him, or monitoring his return, or safety. They are also aggrieved that although he had been assessed for the risk of self harm or suicide on a number of occasions during his admission, no assessment had taken place on the day he left the unit or during the 2 days before. They believe that if these measures had been in place and properly adhered to, then the tragic end to this man’s life could have been avoided.
Victoria Price of Price Slater Gawne is acting for the family.