A recent inquest has heard that medical staff made the decision to allow a patient who was suicidal to leave the psychiatric hospital where he was being treated based on “very limited information”.
The family was represented at the inquest by Denise Broomfield [one of the solicitors here at Bonallack and Bishop], who is head of our medical negligence/personal injury team and who offers a highly specialist inquest representation service.
Peter Bedford, Berkshire coroner, highlighted “serious shortcomings” in the way that Timothy Painter was cared for during his stay at Prospect Park Hospital. Mr Painter killed himself 22 days after leaving hospital.
A local resident, Mr Painter’s body was found hanging in Bartholomew Woods in Tidmarsh on 12th April 2013. He was 41.
He was given permission to leave Prospect Park Hospital where he was being treated as an inpatient on March 21st to do some shopping. This was the last time he was seen.
The decision to allow Mr Painter to leave the hospital was made by a nurse, Jessica Reeve. She unsuccessfully tried to consult a doctor on the matter so then talked the matter over with the ward manager, who agreed to allow the patient to leave without looking at his notes or speaking to him.
Mr Painter was seen shortly after leaving the hospital in a supermarket car park, by one of the hospital support workers. She said that although Nurse Reeve felt the patient had appeared well, she thought he appeared to be “anxious and not himself”.
Timothy Painter was first admitted to Prospect Park on March 16th, after stating that he was struggling to cope and was feeling suicidal.
The inquest was held in Windsor, and heard that Mr Painter had been suffering from anxiety and depression for over a decade, and usually controlled his condition with anti-depressants. Since November 2012 his well being had deteriorated and there was growing concern about him, and about his family.
At the time of his admission there was no space in Prospect Park hospital so Mr Painter was temporarily accommodated in Heatherwood Hospital until a bed became vacant. He finally was admitted as a Prospect Park Patient on 18th March.
Unsatisfactory patient care – the evidence
A Serious Incident Review Report was prepared on behalf of Berkshire Hospitals Foundation Trust by Dr Elizabeth Clifford. She identified seven areas where Mr Painter’s treatment had not been good enough.
1. Lack of consultation with close relatives
2. Not being assessed by a psychiatric consultant
3. No reviews of his care plan or a risk assessment being carried out
Guidelines state that a patient’s risk assessment should be looked at again 3 days after they are admitted.
Delivering his verdict, the Coroner said that “on the balance of probability Mr Painter would not have been granted leave” if he had been assessed by a consultant. He could have either have been persuaded to stay in hospital, or would have admitted his suicide plans.
The Coroner also heard that the frequency of observations on Mr Painter was decreased from every 15 minutes to once per hour without any input from a senior consultant, which goes against the hospital’s own policy.
Throughout his stay in both hospitals, the only doctor who saw Mr Painter was Dr Alexandra Henson – a junior member of staff who had only been training in psychiatry for three months. Peter Bedford stated that “too much reliance” had been put onto Dr Henson.
Mr Bedford said when summing up that he was satisfied that the Trust taken steps to try to prevent any such incidents in the future.
Denise Broomfield said, at the conclusion of the inquest, that the family were satisfied with the outcome.
Lost a loved one? Want representation at an Inquest? Call our Solicitors
Very few solicitors offer a specialist inquest representation service. However, here at Bonallack and Bishop we do – and regularly represent clients and inquests regionally throughout Wiltshire, Hampshire, Berkshire, Somerset and Dorset.
For more information and FREE initial phone advice from a solicitor specialising in Fatal Accident Claims and Inquests, get in touch with our Denise Broomfield today;
- Call us on FREEPHONE 0800 1404544
- Or email using the contact form below/li>