Expert Medical Lawyers Urge NHS Reform To End Preventable Deaths

Medical negligence experts representing the family of a father-of-two who hanged himself after the NHS Trust in charge of his care ‘failed’ him by not admitting him to hospital say the lessons learnt from his death must result in nationwide improvements to mental health services.

The call comes after expert lawyers at Irwin Mitchell secured an undisclosed settlement from Birmingham and Solihull Mental Health NHS Foundation Trust for Wayne Grew’s wife Lisa and two young children following ‘significant’ failures in his care before his suicide.

Refuse wagon driver Wayne, 37, hanged himself from a tree in Queen Elizabeth Park in Birmingham on 4 March 2011 after becoming depressed from the fear that he might lose his job due to council cuts. 

He had repeatedly been seen by mental health specialists after threatening to take his own life, including writing a suicide note and being seen coming back from nearby woods with a rope, but the day before his death it was decided to reduce his medication and visits by the home treatment team, who were not fully aware of his medical history.

An inquest into Wayne’s death, which concluded in February last year, highlighted a catalogue of failures by the Trust including failures to establish a recent history to inform decision making about Wayne’s risk of suicide and a failure to explore exactly what happened when he went into the woods with a rope to properly assess whether he should have been admitted to a specialist mental health unit.

HM Deputy Coroner Sarah Ormond-Walshe recoded a narrative verdict and recommended the Trust use a portable computer between consultations to remind staff of medical records and refresh their memory.

In a letter of apology sent to Lisa in April from the Chief Executive of the Trust, following a full admission of liability secured by Irwin Mitchell, he confirmed: “Your husband should have been admitted to hospital and regretfully these failures by the Trust may have contributed to his death… I am extremely sorry that this Trust failed your husband and it has resulted in the most tragic of outcomes.”

But Lisa, who brings up the couple’s children Darcy, nine, and Ruby, six, backed by her legal team at Irwin Mitchell, says she remains concerned about the number of similar cases that jeopardise the safety of other mental health patients.

Tom Fletcher, is a medical law expert at Irwin Mitchell’s Birmingham office. 

Expert Opinion

Our investigations found that there were significant failures in Wayne’s care that left him able to take his own life, despite multiple pleas for help in the weeks before his death.

“We are pleased that the Trust has taken responsibility for these failures and that we have been able to successfully conclude the case, however we share Lisa’s concerns about mental health services across the country.

“This is unfortunately not an isolated case and across Irwin Mitchell we see similar shortcomings by other Trusts specialising in mental health. It is vital that they work together to share best practice, but also highlight errors that could have been prevented. This will ensure similar failings are not repeated and that mental health patients are given the best possible care, wherever they live.”
Tom Fletcher - Partner

Lisa, 41, who lives in Rubery, said: “I am pleased that the Trust has admitted its failings and confirmed improvements have been made in risk assessment training to ensure no one else slips through the net like Wayne did. I would like confirmation that the Trust is now using portable computers as suggested by the Coroner though.

“However it seems that every week there is another story about someone who has been let down by their local mental health services and it simply should not keep happening. For Wayne’s death not to be in vain, improvements must be made across the country to services so that people are given the specialist care they deserve.

“Nothing can bring Wayne back or make up for what’s happened but knowing his death has resulted in serious change for the better that could save hundreds of other lives would be a fitting legacy and help us focus on rebuilding our lives.”

Timeline of events:

• Nov 2010 – Wayne receives text from colleague about potential redundancies
• 8 Nov 2010 – Wayne visits his GP with symptoms of anxiety, low mood and problems eating, he is given anti-depressants
• 10 Nov 2010 – Wayne returns to his GP as symptoms have not improved and he is prescribed a further anti-depressant.
• 13 Nov 2010 – Wayne is seen by the out of hours service and was diagnosed with ‘acute anxiety’
• 15 November-29 November 2010 – Wayne visits his GP four more times and his medication is continually reviewed
• December 2010 – Wayne’s poor mental state continued.
• 10 January 2011 – Wayne tells his GP he is having suicidal thoughts, he is given further medication
• 3 February 2011 – Wayne has a panic attack at work and Lisa takes him to City Hospital where he informed a psychiatric nurse about his suicidal thoughts. She made arrangements for the Trust’s Home Treatment Team (HTT) to visit him later that evening. No one visited him that night.
• 4 February 2011 – A doctor from the HTT visits Wayne who notes his symptoms and suicidal thoughts however no diagnosis or suicide risk assessment is made. Wayne was not referred to the Longbridge Health Centre Team for a further four days.
• 9 February 2011 – Wayne was seen at the psychiatric clinic at Longbridge but no assessment of suicide risk was made.
• 22 February 2011 – Lisa visits Wayne’s GP to inform she has found a suicide note from Wayne and his mum had phoned her to let her know one of his friends had seen him coming out of the woods with a rope. The GP speaks with a doctor at Longbridge and requests that Wayne be detained in hospital. The Longbridge doctor refuses without seeing the note or reassessing Wayne, and disagrees that he was suicidal. A locum from the HTT visits Wayne later that day but fails to adequately assess his suicide risk
• 1 March 2011 – Wayne’s medication is reviewed by the HTT and is informed that there will be alternate day visits. He is told to avoid being alone as his mood remains low and agitated
• 3 March 2011 – Wayne’s case is discussed at a multidisciplinary team meeting and a plan is made to reduce medication, start anxiety management, reduce visits and discharge as soon as possible
• 4 March 2011 – Wayne is found hanging by police in Queen Elizabeth Park

If you or a loved one has suffered as a result of mental health negligence, we may be able to help you claim compensation. See our Medical Negligence Guide for more information.