15 Oct Inquest finds failings by psychiatric hospital contributed to death of patient

Gold Jennings represented the family of a patient who was permitted to leave an acute psychiatric ward at Springfield Hospital, managed by South West London and St Georges Mental Health NHS Trust, when they should not have been.

The Coroner concluded that a series of failures by nursing and medical staff to properly identify, document and communicate to other staff the plan that any leave should have been escorted contributed to the self-inflicted death. He found that the failure of staff to communicate with the family was also causative, as was the failure to prevent access by non-staff to the staff only area of the hospital stairwell leading to the secure door to the car park. The failure to agree and document when the patient would return from leave, and the failure by staff to challenge him before opening the secure door to the car park, were found to be possibly causative.

The Coroner also issued a Prevention of Future Deaths (PFD) report at the conclusion of the inquest, highlighting his ongoing concern that safety planning around voluntary patients leaving the hospital has not been given the prominence it requires.

The patient’s family were represented by Tim Lloyd and Rithiga Rahulotchanan of Gold Jennings, and barrister Lance Baynham of 1 Crown Office Row.

For further enquiries or to discuss representation following a death in similar circumstances, please contact Tim Lloyd on 0208 445 9268 or tim@goldjennings.co.uk.