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
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
Report of a review in respect of Mr C and the provision of Mental Health
Services, following a Homicide committed in October 2006
Inquests, Suicide, Suicide Prevention, Euthanasia and associated legal
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-
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.
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."
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
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
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
Tragedy of train suicides, Tottenham, Wood Green & Edmonton Journal, 9th October
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
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
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,
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.
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.
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
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
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
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."
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
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
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
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.
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
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