Expert Lawyers Secure Justice For Family But Say Lessons Learnt Must Be Shared Across The NHS

The wife of a road safety engineer who took his own life by stepping in front of a train after his repeated requests for help from psychiatrists were ignored said the case highlights the ‘poor state’ of mental health services in the UK.

Peter Bane, 48, from Happisburgh, Norfolk, died when he was hit by a train on 16 February 2010. The father-of-three was found with a suicide note in his pocket and had told Norfolk and Suffolk NHS Foundation Trust that he was contemplating taking his own life on at least three occasions in the two weeks prior to his death.

His heartbroken wife Angela instructed medical law experts at Irwin Mitchell to investigate whether more could have been done to prevent her husband’s suicide.

She is speaking out after the Trust accepted that had Peter been admitted to a psychiatric hospital and given appropriate treatment on 5 February 2010 when he asked mental health professionals for help, his suicide 11 days later would probably have been avoided. An undisclosed settlement from the Trust has now been agreed.

During an inquest held in February 2011 it was revealed that information about the severity of Peter’s condition was lost in the process of referral from his GP to mental health services because the calls were received by receptionists, rather than mental health professionals, who have the responsibility of ensuring vital information is recorded. 

Assistant Coroner for Essex Mrs Eleanor McGann wrote a report to the mental health trust asking for action to prevent a similar fatality.

In its response the Trust confirmed that a single referral system had been implemented, administrative staff had been reminded of the importance of accurate and complete message taking and the referral form has been updated to include the message takers name so individual’s work can be monitored.

Angela has now backed calls from her legal team at Irwin Mitchell for the lessons learnt from Peter’s care to be shared with mental health services across the UK to try and improve care and protect patient safety in future.

Anita Jewitt, a medical law expert at Irwin Mitchell’s London office represents the family.

Expert Opinion

Peter Bane was a hardworking, professional man who is sorely missed by his family and friends. Peter suffered from occasional episodes of depression but managed appropriately; he recovered and returned to work. Many people who knew Peter were not aware that he suffered from depression, as he actively tried to manage this and always sought help when he needed it.

“Peter and Angela did all they could to seek out help in the correct way and Peter referred himself to mental health professionals. But unfortunately at this stage, the loss of vital information and poor communication let the family down with tragic consequences and is totally unacceptable.

“Patient safety should be the number one concern of health professionals and the signs could not have been clearer that Peter was very worried that he would hurt himself. If the mental health professionals had received all of the information, unfortunately it appears that Peter’s death could have been avoided.

“We welcome confirmation from the Trust that improvements have been made to prevent a similar tragedy from happening again but we would expect these lessons learnt to have been shared across NHS mental health services to improve standards as a whole.” Anita Jewitt - Partner

Angela added: “Peter was let down when he needed professional help most and we continue to be amazed that the Trust had such a poor referral practice in place given the severity of the types of cases receptionists were expected to handle.

“As we hear more and more news about cuts to mental health services and budget restraints, what happened to Peter only goes to show what a poor state many mental health services in the UK are in.

As a family who lost a loving husband and father because of inadequate procedures that jeopardised the safety of vulnerable people is both infuriating and heartbreaking.

“We are pleased to hear that the Trust has implemented new procedures to try and prevent any other errors being made but we hope that this will now be rolled out across the UK to ensure no other patient’s safety is compromised in a similar way.”

Read more about Irwin Mitchell's expertise relating to mental health claims.