A young father who took his own life while an inpatient at Bedford Hospital’s Weller Wing may still be alive today if a proper care plan and risk assessment had been put in place, an inquest heard.
‘Serious failings’ by medical staff at the unit which was run by South Essex Parthership Trust at the time, meant 30-year-old Richard James Jackson’s condition was not properly managed or treated, a coroner has ruled.
Mr Jackson was found hanged in his bedroom at the mental health wing on June 10, 2014 – four days after being admitted via A&E after he had drunk a bottle of aftershave.
Senior coroner Thomas Osborne said: “If the appropriate treatment had been put in place to deal with Richard’s alcohol problem and his adjustment disorder then on the balance of probability he would not have taken his own life.
“There was a failure to carry out an adequate risk assessment and a failure to formulate an adequate care plan, which resulted in a missed opportunity.
“I find there was a minimisation of Richard’s suicide risk, I find there was a lack of knowledge on the part of the nurses and the clinical staff.”
At the time of Mr Jackson’s death the ward was being run by South Essex Partnership Trust but since then the East London NHS Foundation Trust has taken over.
During the inquest, held at Ampthill, consultant psychiatrist and medical director of Dorset Healthcare University NHS Foundation Trust, Dr Laurence Mynors-Wallis, an independent witness called by the coroner, said: “I believe the lack of a care plan was fundamental to Mr Jackson’s suicide.”
Mr Jackson – an ambulance driver and former prison officer, had been struggling with losing his home, not seeing his daughter and believing he had also lost his job. He had been battling alcohol addiction for many years and had a history of suicide attempts and self harming.
The inquest heard that on the day of his death mixed messages were given to Mr Jackson and his family about his discharge from hospital. The consultant in charge was considering transferring him to another ward, a nurse had contacted the YMCA about housing arrangements and another nurse had spoken to Mr Jackson’s mother Judith about him going home to the family home in Bedford.
Dr Mynors-Wallis said: “I find it at best surprising and at worse shocking that the team did not really have a shared plan.
“How can you understand how Mr Jackson was feeling if you didn’t know if he was being discharged to the YMCA, to his mother or transferred to another ward?”
On June 10 last year, Mr Jackson had told a nurse he was feeling ‘10 out of 10 depressed’, which was not investigated further and his mother had voiced serious concerns about her son’s behaviour when she was with him that evening. She told the hearing: “It wasn’t Richard, we were so, so shocked.”
During his evidence Dr Mynors-Wallis said: “I would have thought it was just decent nursing care that if someone said I feel ‘10 out of 10’ you would have a conversation. It is basic nursing care and common humanity.”
Mr Jackson was pronounced dead just before 10pm after attempts to revive him were unsuccessful. The cause of his death was recorded as hanging and terminal aspiration.
Deputy director of nursing Diane Hull from the East London Foundaiton Trust, which now runs the Weller Wing, told the hearing changes that have been made. These include a review of care plans, weekly audits, recruiting more senior nurses who review care plans on a daily basis and spot checks.
“We want to get it right,” she told the coroner.
Mr Osborne told the family that he is ‘fairly certain’ that things will change. “If they do then you will at least have the comfort of knowing that Richard hasn’t died in vain,” he said.