Summary from E-Bulletin of DSA November 2008.doc

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Summary from E-Bulletin of DSA November 2008.doc

  1. 1. Inquiries / Reviews / Complaints: completed / published / being set up / sought : Summary from the E-Bulletin of DSA : November 2008 Report critical of killer's care, BBC News, 22nd October 2008 The care received by a mentally ill patient before he stabbed a 56-year-old woman to death has been criticised. Christopher Devine, 23, from Rhyl, Denbighshire, killed Sandra Bowring (also known by her maiden name Vincent) after they met at a psychiatric unit. Healthcare Inspectorate Wales (HIW) said steps which would have made the killing unlikely were not taken. The North Wales NHS Trust apologised and said a review had been carried out making services "much safer". The Conwy and Denbighshire adult mental health and social care partnership said it accepted the findings of the HIW report. In its report, HIW said: "While it cannot be guaranteed that Sandra Bowring's killing could have been prevented, steps that may have rendered the homicide unlikely were not taken. There are important lessons to be learned from this tragic case to ensure that mental health services are better able to minimise the risk of similar incidents in the future," said HIW chief executive Dr Peter Higson. North Wales NHS Trust chief executive Mary Burrows said she wanted to "publicly apologise" for what had happened and said she was "deeply concerned" about the report's findings. Devine stabbed Ms Bowring at least five times in October 2006. She was able to tell who had attacked her, but died two days later. Devine, who had a long history of behavioural problems, had initially denied murder but changed his plea during a trial at Caernarfon Crown Court in 2007 and was jailed for life. The pair had met while they were patients at a psychiatric unit at Ysbyty Glan Clwyd, Bodelwyddan in 2005. The trial heard she had become "strangely, deeply attracted" to him and one of her relatives had said she was "obsessed" with him. But Devine, the court heard, had previous convictions for violence involving the use of knives. The HIW report said he had "a personality disorder and complex needs" and had "difficulty accessing services ..." It went on: "... the resources available were not robust enough to provide the intensive support he required to manage his complex and difficult behaviour". Amongst other findings the report concluded that "once diagnosed with a personality disorder there was a belief that mental health services could do nothing for [Devine]". There were also failings in the approach of local services to assessment and risk management. In August 2006, following a case of deliberate self harm, Devine requested that he should be detained under the Mental Health Act, but was told that it would be inappropriate. The report also said Ms Bowring had reported a serious assault at the hands of Devine to North Wales Police but it was not followed up. When she was admitted to the psychiatric unit on 21 September last year she told nurses she had suffered a broken nose and later reported the incident to police. But on 24 September she was still awaiting a visit from officers and police later said they had no record of her complaint. However, since the completion of the review police have now confirmed they did receive a call from Ms Bowring and the matter is being investigated. Jill Galvani, director of nursing and patient services for North Wales NHS Trust, said: "First I would like to say that we are sorry for what happened and would like to extend our deepest sympathy to the families involved in this tragic case." She said a review had been carried out immediately after Ms Bowring's death and as a result of measures taken the trust was confident its services were now "much safer". Ann Lloyd, NHS Wales chief executive and head of the Welsh Assembly Government's health and social services department, said: "We must all resolve to learn from these situations and identify changes needed to reduce the risk of such events happening again. Local health and social service bodies have already prepared action plans to take action to reduce risk in the community. They are taking this tragic event and its aftermath very seriously indeed. Lessons must be learned and changes implemented."
  2. 2. Report of a review in respect of Mr C and the provision of Mental Health Services, following a Homicide committed in October 2006 http://www.davesheppard.co.uk/access/pdf_files/Inq-Devine.pdf Inquests, Suicide, Suicide Prevention, Euthanasia and associated legal issues Hellesdon Hospital patient found hanged, Norwich Evening News, 1st October 2008 A 28-year-old man who suffered from depression and paranoid delusions hanged himself after “going for a walk” in the grounds of Hellesdon Hospital, an inquest heard. Alan David Herring was an inpatient at the mental health hospital and was discovered hanging from a tree by a man walking his dog near the Drayton High Road unit. An inquest into his death, held at the Assembly House in Norwich on Tuesday, revealed he had suffered from varying stages of mental health problems for several months before his death on October 5 2007. The coroner's court heard how the warehouseman from Little Bethel Street was detained under section 3 of the Mental Health Act and had been staying on Waveney Ward at the time of his death. Dr Richard Wales, who at the time of Mr Herring's death was a consultant at Hellesdon Hospital, explained that the patient was first referred for counselling in July 2005 after showing signs of depression to his GP but he was first admitted to the hospital on September 4 last year following a mental health assessment. Mr Wales said: “Mr Herring had a history of anxiety, he was distressed and paranoid. He was admitted to the hospital because he was extremely vulnerable and displaying symptoms most like paranoid schizophrenia. He had smeared paint and food on his walls at home and destroyed his belongings. He was sectioned so we could treat his condition.” During his time at the hospital his condition appeared to stabilise but he was constantly upset at being detained and feared he was becoming “institutionalised”, the inquest heard. He was given “escorted leave” home but he was struggling to cope and was tearful, Mr Wales said, so he was prescribed anti- depressants. Two days before his death he was assessed and while it was recorded he was “unsettled, depressed and anxious” he displayed no clear psychotic symptoms. He had played tennis with occupational therapists the morning of his death and while he was “tired and anxious” he was not displaying any signs of wanting to commit suicide. He was assessed at 10.50am and recorded as being at “low risk” of suicide and self harm as well as “low risk of absconding”. Emma Mertens, a qualified mental health nurse at staff nurse on Waveney Ward, where there were 11 patients that day, talked about how Mr Herring left the ward to go for a walk on the day of his death. Hellesdon Hospital is a low secure unit and some patients are allowed freedom within the grounds although are not permitted to leave the premises. She said: “Mr Herring said he was going for a walk and we decided he needed fresh air. He wrote on the board he was leaving at 3pm and would be about an hour.” A head count is usually made every hour at the hospital but she explained how staff had to attend to a female patient who had been trapped in her room and was “extremely distressed”. At 4.45pm staff were informed Mr Herring had been found hanged. He had walked to a remote part of the ground called Carrobrick, about 15 minutes from the ward, and hanged himself from a tree. Teddy Patterson from Hellesdon was walking his dogs in the wooded area in the grounds of the hospital at about 4.30pm. He said: “Something caught the corner of my eye and I saw a body dangling from the tree. There was no sign of life. I went to the hospital and told the staff.” Summing up the case Mr William Armstrong said a post mortem had revealed Mr Herring had died from a fracture of the cervical spine due to hanging. The jury at the inquest, made up of seven men and three women, could not agree on whether Mr Herring intended to kill himself so an open verdict was recorded.
  3. 3. Woman died after falling, Get Reading, 3rd October 2008 A mum died after falling on her hip during a row with her husband over their son’s bedtime. Mental health patient Kathleen McGuire, 73, died in January this year at Prospect Park Hospital following an operation to fix a fractured hip at Royal Berkshire Hospital on Christmas Day. Mrs McGuire, who was cared for at her home in Rushbrook Road, Woodley, by her husband Thomas, had fallen during a row with him on December 20, over whether their son David, who has Down’s syndrome and is also cared for by Mr McGuire, should go to bed. At the inquest into her death on Tuesday, Mr McGuire said: “She was pulling on his arm and I tried to stop her but she would not let go. As I tried to get her off him she fell, but she did not seem injured and that was the end of it. “It was only two days later when she started to complain about a pain in her leg and as soon as she did, I called an ambulance.” The inquest heard how Mrs McGuire refused to go to hospital with the ambulance crew so they advised him to call the doctor. He called the out-of- hours service and the doctor reported she had not been eating or taking her medication for three weeks, but reported no leg injury. On Christmas Eve, Mrs McGuire was visited again by the doctor and a community psychiatric nurse and was sectioned to be taken into hospital. A scan revealed a fractured hip and Mrs McGuire was operated on at the Royal Berks on Christmas Day and transferred to Prospect Park for recovery on January 9. She died on January 14 from deep calf thrombosis that caused a clot in her pulmonary arteries. The inquest heard she had suffered from severe depression for 10 years and had stayed at Prospect Park from August to November 2007 after refusing to take her medication and neglecting her personal hygiene. But when her state of mind improved, she returned home. Mr McGuire had admitted kicking his wife causing her an injury on her leg before her admission to hospital in August, but it was something she denied and those involved in her care were happy for her to return to the family home. But after only a month at home, things started to deteriorate. Berkshire coroner Peter Bedford said: “The image I am presented with is that Mrs McGuire, when she was ill with her mental health problems, could be a challenging individual. The burden of care fell very firmly with her husband who was also caring for his son, but he was accepted unanimously as a proper carer. There was an incident in August 2007 when he kicked his wife in the shin, but he just needed help rather than it being any more sinister. She fell in December but it was entirely an accident and it is not 100 per cent clear whether the fracture was from that fall as she felt no pain until two days later, although it is unlikely that she fell on a separate occasion that was unnoticed.” Recording a narrative verdict, Mr Bedford said the precise mechanism of her fall remained uncertain and that she died following complications of surgery on a fractured hip. Derby's 'public execution', BBC News, 4th October 2008 Seventeen-year-old Shaun Dykes killed himself by leaping from a multi-story car park in Derby city centre. Tragically, teenage suicides are not unusual, but what made the case of Shaun Dykes so shocking was that he was allegedly heckled and even goaded by members of a crowd gathered at the scene during the three-hour ordeal on Saturday, 27 September. The crowd comprised a wide range of ages. Today Programme reporter Andrew Hosken visited Derby to try and piece together events which led to Shaun's death. Alasdair Kay, director of the Derby City Mission, witnessed much of what happened that day and told Today: "I was shopping with my family and couldn't work out why it was taking so long to get out of the car park ... (but) as soon as I came out I saw a young lad at the top of the parapet at the shopping centre." He likened the scene to that of a "public execution". "People were filming … we could hear people shouting "jump you …" followed by a stream of expletives. They weren't all just young people, some were middle-aged. To be honest with you I was sickened."
  4. 4. Also in the multi-story car park was Haley Mackay and her team of valets washing cars. She said: "I saw him up there but didn't see him fall." Asked whether she heard the goading she said yes and called it "disgusting" and "wrong". But she also said the police must take some of the responsibility for what happened that day. She said they "could have cordoned it off further up the road, so that the crowd would not be there." It has since been claimed onlookers took photographs of Shaun's body after he had thrown himself off the building. But who was Shaun Dykes, the vulnerable young lad who faced such goading? He was raised in a village not far from Derby, his parents had long separated and his mother had recently split from her boyfriend. After dropping out of a recent business course he had returned to school to study his AS levels and dreamt of becoming an accountant or a pilot. He also worked part-time at his local pub in his home village of Kilburn. On the night before he died he did his usual shift alongside Craig Doxey, a fellow waiter and his best friend. Craig found time during another shift to speak about his friend. "He was always smiling and laughing about stuff. I think if it wasn't for the crowd, Shaun would have got down and got some help from all his mates, work colleagues and the police." One of Shaun's school friends, Rebkha Minkley, added: "He was the best person anyone could have asked to meet. He always came in, in the morning with a smile on his face." Not only can Rebkha not come to terms with the death of her friend, but she does not understand how people could have got a thrill over watching him die. "To be up there in the state he was in, and then for people to tell him to jump, it made me feel sick ... I can't cope with it." Shaun went to school at Heanor Gate Science College, eight miles from Derby, situated in a largely white, working-class area. He was openly gay and considered to be a "breath of fresh air", despite a troubled home life. Rob Howard, the school's head teacher, said: "I feel very angry that there are people out there who are so desensitised to life that they just see it as a film or a soap opera. I don't think they realise what the consequences of their actions are going to be, but it is clearly disturbing." Apparently Shaun Dykes left a suicide note. It is likely that he was badly affected by the breakdown of an important relationship. But perhaps the reasons for his death are less important than what it revealed about the nature of a handful of ordinary men and women on a bright Saturday afternoon in England. Cannabis warning after teen's hanging, Eastern Daily Press, 8th October 2008 Cannabis users were yesterday urged by a Norfolk coroner to learn from the death of a young man who hanged himself. Greater Norfolk coroner William Armstrong said Oliver Lindon, who was found in his Norwich flat on December 12, 2006, died as a result of hanging while in a disturbed state of mind. A number of doctors and nurses who treated the 25-year-old for mental-health problems in the weeks leading up to his death told the inquest he regularly used cannabis. Mr Armstrong said he could not speculate if cannabis had caused Mr Lindon to hang himself but added: “There is, and has been, very clear and compelling evidence from a number of professionals at this hearing that his mental health was severely impaired as a direct result of his use of cannabis. Anyone who needs to be convinced of the damaging effects of cannabis use should have been here.” A post-mortem examination showed Mr Lindon did not have any illegal substances in his blood when he died, however speaking at the hearing, Rebecca Horne, a consultant psychiatrist, said the effects of cannabis could last for weeks. Dr Horne said Mr Lindon acknowledged the drug had “messed with his head”. Following the hearing Mr Lindon's mother, Sandra, said she believed her son had existing mental-health problems that were made worse, but not caused, by his cannabis use. She said: “I don't think it was purely down to cannabis. He took his life when he wasn't under the influence of cannabis.” The inquest heard Mr Lindon had first been referred for a mental health assessment in 2003, had tried to hang himself in August 2005 and had twice taken an overdose in 2006. He was
  5. 5. taking anti-psychotic medication at the time of his death and had been detained at Hellesdon Hospital under the Mental Health Act two months before and was moved to Basildon Hospital before being discharged. In the days leading up to his death, Mr Lindon was assessed by health-care workers at the hospital and visited by doctors at his home but it was decided he did not need to be detained. Mr Armstrong said an internal investigation into the death was being carried out. He said: “Any lessons that can be learned will be learned.” Mrs Lindon said she hoped the services concerned would learn something from her son's death. She said: “The system overall has got some huge, yawning gaps. You all do a good job but there are huge improvements to be made.” Tragedy of train suicides, Tottenham, Wood Green & Edmonton Journal, 9th October 2008 Two patients threw themselves in front of trains after mental healthcare teams failed to "properly" investigate their suicidal intentions, a coroner has ruled. Keen photographer Miss Helene Stoll, 43, of Shelbourne Road, Tottenham, was killed by an express train on Valentine's Day this year. She died just hours after being assessed as at "low-risk" of suicide by her mental healthcare co-ordinator, Hornsey Coroner's Court heard. A second patient, David Cornforth, 38, of Genista Road, Upper Edmonton, had even spoken of his "plan and intent" to jump in front of a train with mental healthcare staff, just a day before doing so on October 16 last year. In both cases the inquest jury highlighted "failings" by the Barnet Enfield and Haringey Mental Healthcare Trust in not quizzing the victims further during their assessments, or taking action afterwards. French-born Miss Stoll, a former children's nursery worker, had been experiencing suicidal thoughts in the months before taking her own life, the court heard, and had attempted suicide in 1990. But her healthcare co-ordinator Janet Blair revealed she had not pursued these suicidal thoughts during the risk assessment, because they were "quite usual". Miss Blair added that Miss Stoll had denied any intent to go through with committing suicide during a meeting with her psychiatrist 10 days earlier. On the morning of her death, Miss Stoll was not behaving out of the ordinary, and social worker Miss Blair graded her risk of suicide as "low". Just hours later, at 1.45pm, Miss Stoll jumped from the platform at Northumberland Park station, Tottenham. Returning a narrative verdict, the jury said: "We believe Helene Stoll committed suicide as a result of failings by the mental healthcare trust to properly investigate Miss Stoll's thoughts of suicide and accurately identify the risk of Miss Stoll taking her own life." A jury also ruled that David Cornforth committed suicide at Angel Road station, Edmonton, by standing in front of a train. In its narrative verdict, the jury said his suicide "was caused by serious failures of the mental health care trust in failing to document and positively act on" plans he had revealed to staff about jumping in front of a train. A trust spokeswoman offered "sincere condolences" to the families involved. She said it had undertaken "extensive internal inquiries" into the surrounding circumstances. Its inquiry into Miss Stoll's death is ongoing. She added that "any lessons for improvement are learned as quickly as possible". And she said: "We will be studying our procedures and our reports into these two suicides, along with the juries' verdicts." The trust admitted "shortcomings which we deeply regret" over Mr Cornforth's death, she continued, and has improved access to patient records, including risk assessments for "relevant" staff. It now ensures patients referred to the home treatment team will be seen within 72 hours and is arranging trust-wide training on risk assessment and management. Dr Pete Sudbury, trust medical director, added there was "no way of determining which individuals" who are "at higher risk" of suicide will make attempts on their own life. Electrician discovered dead in bath after plea for suicide pact, Islington Tribune, 10th October 2008 An unemployed electrician who tried to talk his partner into a suicide pact at their Clerkenwell home took his life in spite of her refusal, an inquest heard this week. Divorced Francis Cottrill,
  6. 6. 55, hung himself from a cord at his Mount Pleasant home in July after an argument with his partner, Aurora Erguiza. Giving evidence at a St Pancras inquest on Tuesday, Ms Erguiza said: “He said: ‘We have to die together’.” Of his later suicide, she said: “I never thought he would do that to me.” She gave an emotional account of how, after Mr Cottrill asked her to commit suicide with him, she left their flat and went to seek help from his friends. But, when she returned to the flat with a friend it was too late. After breaking down the bathroom door, they found Mr Cottrill lying in the bath with a blue cord around his neck, having apparently hung himself from a fixture in the room. A medical report, read out by coroner Dr Andrew Reid, revealed that around a year before Mr Cottrill’s death he had been assessed and was not seen as a danger to himself. The report, following a referral by his GP Dr Kim Ruddy at Amwell Practice, read: “He wasn’t considered to have an active mental health problem or be depressed.” Dr Reid recorded a verdict of suicide. “This was a voluntary and deliberate act,” he said. Ms Erguiza, speaking outside the court, said of her partner: “I loved him.” 'No effective action' to prevent 'murder-suicide', Fenland Citizen, 10th October 2008 The death of a university student and subsequent suicide of her killer in Derby could have been avoided, a coroner has said. Police believe Iraqi Kurd Khalid Peshawan murdered Halimah Ahmed, 19, on November 26 last year before hanging himself. The pair's bodies were found the following day. Coroner Dr Robert Hunter returned a verdict of unlawful killing for the death of Miss Ahmed. But in a narrative verdict for the inquiry into Peshawan's suicide, he said "no effective measures" were taken by mental health staff after the 33-year-old spoke of suicide and concerns that he may harm his friends. In a two-day inquest at Derby Coroner's Court, details emerged of Peshawan's deteriorating mental state in the weeks before the deaths. A community psychiatric nurse flagged up her concerns about the failed asylum seeker, saying he "fully intended to kill himself" and that he was a serious risk to others. But attempts at conducting the assessment vital to sectioning him under the Mental Health Act failed on three separate occasions because an approved social worker could not be found. Summing up, Dr Hunter said: "Had Mr Peshawan been admitted (to a psychiatric unit) voluntarily or as a detained patient and had a full and comprehensive assessment been conducted over a period of time then, on the balance of probabilities, the tragic events which occurred on November 26 would have been avoided." An internal review carried out by the Derbyshire Mental Health Services NHS Trust found that the tragedy could not have been predicted. But the inquiry was branded in court by Miss Ahmed's family as a "whitewash" that "glossed over" systemic failures to manage the care and treatment of Peshawan. Woman who swallowed anti-freeze dies after refusing treatment - because doctors feared 'assault' claim if they saved her, Daily Mail, 17th October 2008 A young woman who attempted suicide was allowed to die because hospital staff feared they would be accused of assault for ignoring her wishes, an inquest heard. Kerrie Wooltorton arrived fully conscious in hospital clutching a 'living will' in which she stated she did not want to be saved and was '100 per cent aware of the consequences'. The former charity shop worker called an ambulance after drinking the anti-freeze at her flat. The consultant who would have treated her for swallowing anti-freeze sought legal advice before deciding not to intervene and Miss Wooltorton, 26, died the following day. Staff at Norfolk and Norwich University Hospital complied with Kerrie Wooltorton's wish not to receive medical treatment, an inquest heard. The case drew astonishment yesterday from anti-euthanasia organisations which said living wills should only apply when the patient is incapable of stating their wishes. They accused Norfolk and Norwich University Hospital of allowing the document to 'intimidate' them into allowing Miss Wooltorton - who had an untreatable personality disorder - to die when they should have been fighting to save her life.
  7. 7. Consultant renal physician Alexander Heaton told the inquest in Norwich that the hospital's medical director and legal adviser informed him Miss Wooltorton clearly had the mental capacity to make the decision about her treatment. Asked what would have happened if he had intervened, he said: 'It's my duty to follow her wishes. I would have been breaking the law and I wasn't worried about her suing me but I think she would have asked 'What do I have to do to tell you what my wishes are?' 'She had made them abundantly clear and I was content that that was the case. 'It's a horrible thing to have to do but I felt I had not alternative but to go with her wishes. Nobody wants to let a young lady die.' Dr Heaton added: 'She was in no state to resist me and I could have forced treatment on her but I don't think it was the right thing to do. 'I feel it would have been assault.' Her friend Melanie Miller, 27, yesterday said she was treated as next-of-kin by Miss Woolterton and had previously given doctors the go-ahead to save her with dialysis. 'When she came round she was angry that she had been saved. Soon after that she wrote the letter saying she did not want to be treated,' she said. Mother-of-two Miss Miller added Miss Wooltorton had been estranged from her parents for many years. She said: 'I know her father was angry that the hospital did not treat her when she was dying. He blames the doctors for her death.' Miss Wooltorton, who lived alone in Norwich, attempted suicide by swallowing anti-freeze on nine occasions in less than a year. Each time she accepted dialysis treatment to flush the toxic solution from her system. She wrote the living will on September 15, however, and drank anti-freeze three days later. When she was admitted to hospital she was 'calm' and 'not agitated', according to Dr Heaton, and verbally confirmed the terms of her living will to staff. A post mortem revealed she died from ethylene glycol toxicity. The inquest, which began on Thursday, heard she had been distressed that her difficulties with intimate relationships might prevent her from having children. She had been regularly admitted to Hellesdon Hospital under the Mental Health Act. But consultant psychiatrist Bernardo Garcia, who saw Miss Wooltorton in the months before her death, said he believed she had mental capacity to make the living will. The Care Not Killing Alliance, which campaigns against euthanasia, yesterday said living wills apply only when the patient no longer has the mental capacity to make and convey decisions about their care. Spokesman Dr Peter Saunders said: 'A mentally competent patient has the right to refuse treatment. 'But you have to ask the question whether someone who attempts suicide nine times in a year is really of sound mind. 'It sounds like the hospital was intimidated by the fact that this woman had a living will. 'Just imagine if the reaction to everyone being wheeled into A&E after attempting suicide was 'Oh, they obviously want to die. Let them go'.' Greater Norfolk coroner William Armstrong adjourned the hearing into Miss Wooltorton's death until later this month to allow her father to prepare a statement. Living wills Euthanasia is a crime in Britain but the 2005 Mental Capacity Act - which came into effect last year - gave people the right to write a 'living will'. This allows them to ask for medical treatment to be withdrawn if they become too ill to speak for themselves. Patients are 'killed' through the withdrawal of food or water tubes, which are considered to be treatment. Doctors who ignore living wills - or ignore instructions of someone appointed by a patient to make decisions for them - commit a crime and can face prison. Earlier this month Justice minister Bridget Prentice promised a review of the law. She has not ruled out changes to the right for patients or their families to order doctors to allow them to die. Car-crash driver detained indefinitely, Bradford Telegraph and Argus, 22nd October 2008 A car enthusiast who crashed killing three teenage girls has been detained indefinitely in a mental hospital. James Houston, 27, who has learning difficulties and never passed his driving test, suffered a brain injury when his Ford Fiesta smashed head-on into a lorry in September, 2006. His passengers Ursula Alokolaro, 16, of Heckmondwike; Gemma Cost, 15, of Batley, and Natalie Donlan, 16, of Dewsbury, all died. Adam Anguige, 26, of White Lee
  8. 8. Road, Batley, who was racing Houston in his Vauxhall Nova, was jailed for ten years in May for causing the girls’ deaths by dangerous driving. Bradford Crown Court heard that Houston, of Croft Cottage Lane, Huddersfield, was easily led and posed a risk of committing a similar offence. Judge Christopher Prince ordered that Houston be detained indefinitely under the Mental Health Act at St Luke’s Hospital, Huddersfield. Judge Prince said Houston, who was found unfit to plead at trial, was guilty of “truly appalling dangerous driving”. The car he bought in defiance of his parents, and never taxed or insured, was three abreast when it crashed on Wakefield Road, Huddersfield. Judge Prince said Houston was ‘thrill-seeking’. The judge disqualified Houston from driving for ten years. He said it was hard to conceive a more distressing case. Judge Prince said the girls’ families had demonstrated a resolute and conspicuous dignity and composure throughout the court proceedings. Patient scaled wall before death on M6, The Sentinel, 23rd October 2008 A mental health nurse who became severely depressed escaped from a hospital and walked into the path of a lorry on the M6, an inquest heard. Adrian Quinn, aged 39, from New Road, Ash Bank, died on July 19, last year, on the southbound carriageway near junction 15. Four hours before his death, he used garden furniture to climb over a fence and flee from Harplands Hospital, where he had been sectioned under the Mental Health Act. His inquest heard that 10 people had escaped in the same way in the year before his death. Mr Quinn had previously worked in Hillcrest Hostel in Hanley as a care worker, and was a fit and healthy man who enjoyed running. His partner, Jayne Rushton, described him as a bright, funny and thoughtful person, until his health rapidly deteriorated in the weeks before his death. She said: "It came from nowhere. He became anxious and agitated, was sleeping poorly, and started to think he was a burden. He believed the house was going to be repossessed, but that wasn't based on fact." The coroner's court heard how Mr Quinn used to wake in the night believing people were coming into his home to take him away and torture him. He voluntarily went into Harplands Hospital in Hartshill on July 10. But three days later, he packed his bags saying he wanted to leave and staff sectioned him under the Mental Health Act to make him stay. On July 19, just after midnight, staff saw him outside in the garden having a cigarette. Fifteen minutes later, when they went to lock the door to the garden for the night, he had disappeared. After a quick search of the grounds, they phoned the police. Four hours later, Mr Quinn was hit by a heavy goods vehicle driven by a Polish man on the M6 and died instantly. Staff nurse Gareth Thomas had been responsible for looking after Mr Quinn and 21 other men in a ward in Harplands that night. He had help from a care worker, but the ward was meant to be staffed by another nurse who had earlier been called away to deal with an emergency elsewhere, leaving the ward short staffed. Mr Thomas said: "It was not an ideal situation. We generally had three staff. "We had other patients who had gone over the same fence before. It was six foot." The court heard how garden furniture, which was not bolted down at the time, had probably been used by patients, including Mr Quinn, to help scale the fence. In the 12 months prior to Mr Quinn's death, 10 patients had escaped this way. When staff realised Mr Quinn had disappeared they called his partner, Miss Rushton, on her home number. There was no answer, no message was left and staff did not try her mobile number. Speaking at the inquest Miss Rushton said: "There were four hours between him going missing and being on the M6. If I had been able to get in touch with him, maybe things would have been different." The court also heard evidence from two senior hospital staff, director of nursing and operations David Pearson and medical director Roger Bloor. Both admitted the staffing levels in the ward that night were not "optimal" and that a lot of lessons have been learnt from the incident. Mr Pearson said: "We have learnt from this. The lighting in the garden has been improved and the furniture is bolted to the floor."
  9. 9. Speaking directly to Miss Rushton, he said: "I apologise that you were not contacted." An external inquiry into the incident found that better notes should have been made by those involved in observing Mr Quinn on the ward, and three staff was the minimum required for the shift. North Staffordshire Coroner Ian Smith said: "Adrian Quinn killed himself while the balance of his mind was disturbed, and this was aggravated by circumstances where his personal safety had been compromised." Train suicide patient thought he was being followed, The Northern Echo, 28th October 2008 A mental health patient who killed himself by jumping in front of a train after absconding from hospital believed he was being followed, in inquest was told. Martin Lee Kirkham died of multiple skull fractures after being hit by a National Express train near Northallerton station, North Yorkshire, on March 20. Mr Kirkham, who was 39 and originally from Wakefield, West Yorkshire, was a bank worker. On the day before his death, Mr Kirkham travelled from his home, in Edinburgh, on a train bound for King's Cross, but got off at Thirsk. He was later detained under the Mental Health Act and transferred to the Friarage Hospital, in Northallerton. Mr Kirkham voluntarily spent the night in the hospital's mental health unit, before leaving unannounced, yesterday's (TUE) inquest, at Northallerton Magistrates' Court, was told. Dr Adam Kempster, a forensic examiner for North Yorkshire Police, examined Mr Kirkham. He said: "Mr Kirkham was nervous, quietly spoken and frightened that people were out to get him. Those were the words he used. I concluded that he had suffered some sort of psychiatric breakdown." Mr Kirkham's mother, Marjorie, said her son had been stressed out at work and had been hit hard by the death of his father, in November. She said: "His job was very dog-eat-dog, he would say. The first I knew of him being in North Yorkshire was when the police called to say the Martin was in their care. I said to look after him, because he had recently lost his father. After leaving hospital, he called me from a phone box close to the railway station. He told me not to worry and said that he loved us." Coroner Michael Oakley concluded that Mr Kirkham had killed himself while the balance of his mind was disturbed. Bar Walls man detained, York Press, 18th October 2008 A man arrested by police following an incident on the Bar Walls in York has been detained under the Mental Health Act. The Press reported that police negotiators were called in to talk the distressed man down from the walls. Specialist police officers cordoned off an area of the walls near Station Rise at 7.20pm on Thursday after a member of the public made a 999 call regarding the man’s welfare. The man, who is 35 and from Harrogate, had got on to the walls after dark and was acting in “a distressed and agitated state”. A police spokesman said he threatened officers after they arrived on the scene. The walls are shut to members of the public at dusk, but the man had gained access and was seen running backwards and forwards along a 20ft high section of the ramparts close to the railway war memorial. The road was not closed to traffic and the railway station remained open throughout. Staff from North Yorkshire Fire & Rescue Service and Yorkshire Ambulance Service were at the scene on stand-by. The man was talked down to safety shortly after 10.15pm and was arrested for possession of “a bladed article”. He has now been released from police custody. No further action has been taken against him, he was voluntarily detained under the Mental Health Act and will receive treatment at a specialist hospital in Harrogate.
  10. 10. Man detained after rail incident, Keighley News, 22nd October 2008 More than 44 trains were delayed and two services partially cancelled on the Airedale line after a teenager was spotted standing in the middle of a railway crossing at Steeton yesterday afternoon. The 19-year-old man, from Keighley, was later detained under the Mental Health Act. A British Transport Police (BTP) spokesman said: “The man did not sustain any injuries and was taken to Airedale Hospital, where he remains. BTP and West Yorkshire Police officers attended the incident, which occurred around 3.30pm.” Church roof man released without charge, Rutland and Stamford Mercury, 31st October 2008 A man who was arrested after climbing on top of a church roof has been released without charge. The local man, believed to be in his mid-20s, was detained under the Mental Health Act, after climbing on to the vestry roof at All Saints Church, Stamford, on Wednesday morning. The incident happened at about 9am and police, firefighters and an ambulance attended. The man was brought down safely on a platform ladder at about 9.45am after talking to police officers on the roof. He was arrested and detained under the Mental Health Act and later released without charge. Excerpts reprinted from the monthly e-bulletin compiled by Dave Sheppard Associates : www.davesheppard.co.uk

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