Patient Committed Suicide While Mentally Ill – Inquest Verdict

The jury at a 4 day inquest in Carlisle into the death of a man suffering from mental health problems, reached a verdict yesterday. He had been hit by a lorry on the A6 in Cumbria.

The man in question had been a patient in the Carleton Clinic part of the Cumbria Partnership Foundation NHS Trust since January 2013. He had been allowed to visit the grounds of the unit on unescorted leave, despite the concerns of his family that he would be at risk, as he had a history of self harm and several previous attempts at suicide. Shortly after leaving the ward at around 2.00pm, he had made his way onto the A6 in Cumbria and been hit by a lorry, despite attempts by the lorry driver to avoid him.

Poor communication and inadequate procedures on the ward resulted in a failure to notice that he had not returned to the ward after the normal 30 minutes. In fact, his absence was not noticed at 3.45pm when the Police arrived to ask if there were any missing patients, or at 4.00pm when there was a ward check. His absence was discovered at 5.45pm, some 3 hours after he had been involved in the accident and long after he was due back on the ward. He had been struck by the lorry 15 minutes after he should have returned to the ward.

Despite being taken to the Royal Victoria Infirmary in Newcastle he died of his injuries later.

The inquest heard from his family, the lorry driver, Police, and hospital staff. When summing up the case the assistant coroner Robert Chapman reminded the jurors not to attribute blame or guilt to any of the parties involved when making a decision.

They jury retuned with a verdict of suicide while mentally ill.

Victoria Price of Price Slater Gawne is acting on behalf of the family.

Our report on the inquest can be found here