‘Serious And Inexplicable Omissions In Care’ Contributed To Hucknall Man’s Death, Inquest Finds

  • Gary Mavin was found hanging from the en-suite bathroom door that adjoined his room at a psychiatric hospital in Arnold, Nottinghamshire
  • Inquest into father-of-three’s death found that neglect contributed to his death
  • Nelsons representing the 54-year-old’s family fight for justice

Nottingham Coroner’s Court has found that ‘serious and inexplicable omissions in care’ at Priory Hospital in Arnold, Nottinghamshire contributed to the death of a father of three.

In her conclusion, the coroner stated that “Gary’s case is one of the worst examples of care provided to a vulnerable, mentally ill patient” and that the care he received was “seriously flawed”.

The inquest into his death was initially due to conclude on Monday 19 July after a three-day hearing. However, the inquest was adjourned by HM Assistant Coroner Laurinda Bower to obtain an independent report from a psychiatric expert about the care Gary received prior to his death.

Gary Mavin, of Hucknall, was voluntarily admitted to Priory Hospital Arnold on 31 August 2020 after displaying paranoid thoughts and poor mental health for a number of weeks and attempting to end his own life.

On admission to the Priory, Gary was placed on anti-depressants that were discontinued only one week later due to side effects, without any alternative being considered or provided to him.

Following an incident on 13 September where staff were concerned about the behaviour Gary was exhibiting, they discovered a self-made ligature during a search of his room. He was temporarily detained under section 5(2) of the Mental Health Act for a maximum of 72 hours pending a formal Mental Health Act assessment. He was reviewed at a multidisciplinary team meeting the next day and the decision was made not to proceed with a formal assessment. The section 5(2) detention was left to lapse.

A week later during the night of 20 September, Gary was discovered to be missing from his bedroom and after a search of the hospital’s communal areas, he was found hanging in the en-suite bathroom attached to his room.

The hearing was an Article 2 inquest – an enhanced inquest, which is held in cases where the state or ‘its agents’ (in this case, the Priory Hospital) have ‘failed to protect the deceased against a human threat or other risk’ or where there has been a death under some form of detention, such as the Mental Health Act. In her conclusion, Ms Bower found that neglect contributed to Gary’s death.

Lea Mavin, who was separated from Gary but remained legally married and in close, regular contact, said:

“While it has been a long process, we’re satisfied with today’s conclusion. I feel like our concerns have finally been heard and listened to, particularly by the independent expert evidence, whose report was accepted in its entirety by the coroner.

“While we’re pleased that The Priory has provided evidence to show that it is making the changes needed to ensure that what happened to Gary doesn’t happen again, we feel that the provision of basic care should have been in place at the time that Gary needed it most and the fact that it wasn’t will stay with us forever.  

“The last message I received from Gary was just before half-past ten in the evening on 20 September; he thanked me for my confidence in him and told me that he loved me. When I found out in the early hours of the next morning that he had passed away, I was absolutely heartbroken.

“Telling our sons about what had happened to their father was one of the hardest things I’ve ever had to do – I knew that it would destroy their whole world. We’re completely shattered by losing Gary and it’s very hard to put into words, but I’ve tried to stay strong for our children and they’ve tried to stay strong for me in return.

“Gary was such a kind person who was willing to help anyone with anything – if there was ever a problem, he would be there. He was also a fantastic, hands-on father for our three sons and even though we separated around 12 months prior to his death, he visited us on a regular basis, was the backbone of our family and such a big support for us all.

“That’s what makes all of this even harder to accept, that we were unable to help him through his struggles and that he’s no longer with us.”

Baishali Clayton, inquest specialist, Senior Associate and Solicitor, and Shrdha Kapoor, Trainee Solicitor, both from our Medical Negligence team, have been assisting Mrs Mavin since her husband’s death. Barrister Rachel Young, of Ropewalk Chambers, represented the family in Court during the hearing.

Miss Kapoor said:

“The inquest highlighted many serious concerns about the multiple failures and missed opportunities to properly diagnose and treat Gary’s acute condition in the weeks leading up to his death. It was evident that he was experiencing symptoms of psychosis from early August but was not actively treated for this during his admission at the Priory.

“Gary was admitted to the Queen’s Medical Centre (QMC) on 11 August after a friend rang 999 because he was coughing up blood and exhibiting concerning, paranoid thoughts. Although coughing up blood was a regular symptom for Gary’s diagnosis of chronic obstructive pulmonary disease (COPD), the QMC primarily treated him for alcohol excess and withdrawal – even though he did not have a history of alcohol abuse. His symptoms remained the same and, within hours of his discharge, Gary attempted to take his own life by taking a significant overdose and was hospitalised again.

“There were several failings during Gary’s time at Priory Hospital, not least of which that he was only placed on anti-depressants for around a week before they were withdrawn completely and was not put on any replacement medication. Despite the acute state of his illness, and the presence of psychotic symptoms, he was not provided with any suitable medication. The assessments of his mental health by professionals failed to take into account the delusions and hallucinations he was experiencing, nor were these factored into his treatment plan. The fact that his temporary detention under section 5(2) was allowed to lapse without a formal assessment just one day after Gary had expressed a desire to end his own life, is also a major concern.

“In the day leading up to his death, Priory Hospital staff stated that Gary was doing well. However, text messages sent to the family during this time suggest he was becoming increasingly paranoid. On admission, Gary was put on a high number of observations (four times per hour). He was last observed by a healthcare assistant at 11.12pm who only spoke to Gary briefly through his bedroom door, which we feel was a missed opportunity to engage with him properly and assess his mental health state as he didn’t respond verbally and merely nodded his head.

“It was shortly after this final observation that Gary went into his en-suite and self-ligatured. At the time of the next observation 15 minutes later, staff noticed that Gary was not in his bedroom and that his lights were off but did not initially check the bathroom. This meant they did not discover him until a full search of the communal areas had been conducted”.

Mrs Clayton added:

“Shortly after Gary’s death, the Care Quality Commission (CQC) was notified about the death of a patient after tying a ligature. This led to the independent regulator conducting an inspection visit six months later on 9 March 2021 and placing Priory Hospital in special measures. Among other factors, it found that the facility had not fully assessed all ligature risks and anchor points or taken any action to reduce these as learnings from the death.

“The inquest has revealed glaring oversights by senior clinicians at the Priory in the lead up to Gary’s death. He was thoroughly let down by the systems that were supposed to be in place to protect people at their most vulnerable and suffering with an acute mental health illness.

“The independent expert who reviewed Gary’s case for the inquest found that there were ‘significant deficiencies’ in the care provided to him and, despite all of the evidence pointing to a severe episode of psychosis, the consultant psychiatrist who oversaw Gary ‘effectively ignored’ this element of his illness and was ‘not open’ to this possibility. 

“He was also of the opinion that there were ‘inexplicable and serious omissions’ in relation to numerous elements of the care Gary received, and the overall failure to correctly diagnose and effectively treat his condition contributed to his death. The expert criticised the way fellow clinicians’ concerns surrounding Gary’s presentation were dismissed by Dr Moldavsky – describing it as a ‘red flag’.

“Gary has been let down in the worst way by professionals entrusted to protect him. Today’s finding of neglect brings some hope that the Priory will finally be accountable for its actions and inactions and we hope that the family can begin to find some closure as a result of today’s findings.”

Jodie Anderson, Caseworker at the charity, INQUEST, which is supporting the family, said:

“INQUEST is deeply concerned by the number of deaths occurring at Priory run mental health units nationally. Safety issues have been raised many times before at inquests, particularly regarding risk assessments, monitoring, observations, communication with families and ligature points. Once again these issues were highlighted at the inquest into Gary’s death. 

“The question remains: How many more people must die before the government reconsider commissioning services from a company that repeatedly puts profit over patient safety?

“This inquest conclusion reiterates once again the need for more independent investigation and effective scrutiny and oversight of deaths in mental health settings, to safeguard lives in the future.”

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