A Coroner’s Court has made a finding of neglect against a psychiatric hospital in Dudley after a father-of-one escaped from the secure facility and took his own life.
David Wright, of Tunstall Road, Kingswinford, voluntarily checked into Bushey Fields Hospital on 2nd September 2019 after he reported hearing voices and having suicidal thoughts.
The next day, he was formally sectioned and shortly after, was granted Section 17 leave under the Mental Health Act on the proviso he would be escorted at all times.
A week later, on 9th September, Mr Wright – who was born in Liverpool – absconded from the hospital, which is run by the Dudley and Walsall Mental Health Partnership NHS Trust, and was found hanged at his home by police only a couple of hours later.
A four-day jury inquest into his death before area coroner Mrs Joanne Lees, which concluded on Monday, 26th October at Black Country Coroner’s Court, found there were gross failures in Mr Wright’s care and that his death was contributed to by neglect.
Baishali Clayton, inquest specialist and Senior Associate and Solicitor, and Shrdha Kapoor, Paralegal, from our Medical Negligence team have been assisting Denise Norton, who was separated from Mr Wright as a result of his mental health needs but remained legally married and in close and regular contact, since her husband’s death.
Shrdha Kapoor said:
“The inquest raised many concerns about the lack of processes, knowledge sharing and adherence to procedure in relation to the security and safety of patients at Bushey Fields Hospital at the time of Mr Wright’s death.
“There was also a failure to conduct an occupational therapy screening within 72 hours of his admission, as per trust policy. These gaps allowed Mr Wright to be exposed in way that enabled him to escape from the secure facility and take his own life.
“On the day of his death, Mr Wright attended a group therapy session, which took place in another secure building within the hospital grounds. He was escorted to the session by a member of staff. During the session, another patient became disruptive and left the room with an activity worker.
“Mr Wright became unsettled by the situation and indicated he longer wanted to participate. He then left the room where he spoke with the activity worker in the reception area and expressed that he wished to return to the ward.
“The activity worker asked Mr Wright if he needed to be accompanied back to the ward and whether he was a voluntary or involuntary patient. Mr Wright incorrectly told her he was a voluntary patient and was allowed to leave by himself. The activity worker failed to contact the ward to check his status and opened the locked door to allow him to leave the Therapy Hub unescorted, against trust policy.
“But instead of going back to the ward, Mr Wright made his way home. By the time the missing person’s protocol was instigated and the police conducted a wellness check at Mr Wright’s home, it was sadly too late.”
Baishali Clayton added:
“Taking place over a year after Mr Wright’s death, the inquest revealed glaring gaps in care planning and there was no tailored approach. The care plan also required Mr Wright to self-report when he wasn’t feeling well. This completely put the onus on him, which is something he would not have willingly done because all he wanted to do was go home.
“He had been sectioned under the Mental Health Act because he was at significant risk of harm to himself and it was documented that he should not be unaccompanied at any time, yet he was still able to leave a secure facility very easily.
“Mr Wright was let down in the most devastating and shocking way by the very people and systems that were there to protect his life. The trust has apologised for the failure to ensure that he was escorted back to the ward following his attendance at the Therapeutic Hub on 9 September 2019. It acknowledged that the expected standards and values of the trust were not met at this time, which led to the situation that allowed Dave to abscond from the hospital site that day.
“The jury finding of neglect is very serious. It must have been unimaginable for Ms Norton to hear that but for the actions of the trust, Mr Wright would still be here today.
“While it is appreciated that the trust has since implemented measures so that no other family has to suffer the heartache that Mr Wright’s family has endured, the inquest has simply highlighted the catastrophic failures that led to his death in this case. We hope the family can take some closure from today’s findings.”
Ms Norton said:
“It [the conclusion] will never be a victory because nothing can bring Dave back. But it is reassuring to know that a formal inquiry into his death has validated the concerns I had all along about the standard of care that Dave received.
“It is impossible to put into words how losing Dave has impacted me. It has been devastating and I have found it really difficult to cope with what happened to him.
“We were together for 30 years and I thought I would have another 20 years with him, but it was not meant to be. I am now faced with trying to process his loss as nothing can bring him back.
“On 9 September 2019, the very people employed to protect him let him down in the most fundamental and profound way. I trusted the NHS to look after him and I fully expected to see him again.
“I am struggling to see a world that does not have Dave in it. He was the most kind and generous person I have ever known and likely ever will know. I miss my soulmate.”
A jury was involved because Mr Wright was under the care of the state at the time of his death. Article 2 inquests involving a jury are enhanced inquests held in cases where the state or ‘its agents’ (in this case, the hospital trust) 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.
Barrister Rachel Young, of Ropewalk Chambers, represented the family in Court during the four-day hearing.