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Widow Calls for Improvements In Mental Health Care After Husband Took His Own Life In Hospital Whilst Under 1:1 Observation

Irwin Mitchell Secure Admission From NHS Trust For Failings In Care

28.04.2015

The devastated wife of an electrician who was able to take his own life in a London hospital due to a series of failings in his care has spoken out for the first time calling for lessons to be learnt by the NHS.

Rory Magill, 44, from Uxbridge, in London, was admitted to Hillingdon Hospital on 12 June 2013 following a suicide attempt; Rory had ingested antifreeze. He was assessed by a psychiatric liaison nurse who deemed Rory to require 1:1 observation to ensure his safety.

The nurse assigned to observe Rory on a 1:1 basis went on her break and the care was not handed over to another nurse. Having been left unattended, Rory sadly hanged himself on 13th June 2013.

Following Rory’s death, his wife Anita instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the care Rory received at Hillingdon Hospital, run by the Hillingdon Hospitals NHS Foundation Trust. The Trust has now admitted liability for Rory’s death and said that had Rory been given the 1:1 observation he required, his death would have been avoided.

On admission to Accident and Emergency, the father-of-four was advised that the hospital did not have the usual drug antidote to the antifreeze and that treatment would therefore have to be in the form of oral alcohol - an alternative antidote.  Rory was known to have issues with regards to problematic alcohol use and Anita expressed her concern about this form of treatment.

Despite this, Rory was prescribed 500ml of vodka and one strong beer per hour. The hospital sent Anita to the local shop to purchase the alcohol as there wasn’t any available in A&E.

Shortly after his treatment had commenced, Rory was transferred to the Emergency Assessment Unit for continued observation. He was assessed by a Psychiatric Liaison Nurse who deemed Rory to be at medium to high risk of suicide and self-harm and recommended that he was provided with 1:1 observation.  

A registered nurse was assigned to Rory’s 1:1 care however shortly after she arrived, she was asked to observe another patient who was being disruptive, leaving her observing two patients in separate bays.

At 04.40am on 13 June 2013, the nurse assigned to Rory’s 1:1 care went on her break and the care was not handed over to another nurse. Rory was therefore left unattended and free to walk around the Unit.

Shortly after the nurse went on her break, Rory went to the toilet unattended and returned with a broken bathroom call bell cord. Rory placed this on the nurses’ station and told the nurse that it wasn’t strong enough to hold his weight. This nurse considered that Rory was attention seeking and did not consider he was going to make a further attempt to end his life.

Between 04.45 – 05.00am, Rory requested a cup of coffee and asked whether there was somewhere else he could sit because he was having “lots of thoughts”. The nurse advised that he could sit in the Day Room, which he did unattended. Rory later returned to his bed whilst the nurses went about their duties, which included observing other patients and completing paper work.  

At approximately 05.45am, the nurses noted Rory to be missing and searched for him. He had last been seen between 05.20 - 05.30am. Sadly, Rory was found hanged in the Day Room and despite resuscitation attempts, he was pronounced dead at 06.40am on 13th June 2013. 

Following Rory’s death, the Hillingdon Hospitals NHS Foundation Trust carried out an investigation and prepared a Serious Incident Report. This report found that there were a series of failings in Rory’s care including:

  • No early psychiatric assessment whilst in A&E;
  • No oral alcohol in A&E;
  • No alternative antidote for antifreeze poisoning held in the Trust (Fornepizole);
  • No request for a follow up assessment by acute psychiatry in relation to Rory’s behaviour on the ward;
  • Inadequate implementation of 1:1 observations according to Trust policy;
  • Inadequate observation of Rory whilst one of the nurses was on her break;
  • Inadequate training for Registered General Nurses and Health Care Assistants in relation to patients with suicidal thought or intent;
  • Inadequate documentation in relation to quantifying the level of observation needed;
  • Miscommunication between staff in relation to specialising (1:1 observation) responsibilities on shift.

Ultimately, the Trust’s report concluded that the root cause of Rory’s death was suicidal ideation and intent with no 1:1 observation at the time of the event.

A one day inquest into Rory’s death held at West London Coroner’s Court concluded today. After the evidence had been heard, HM Senior Coroner Chinyere Inyama said that it was his “clear view that observations at some points amounted to intermittent rather than 1:1 close observations within eye sight or touching distance” and that this “was a failure”. This led HM Senior Coroner Mr Inyama to give the narrative conclusion that: “Mr Magill took his own life, in part because the risk of him doing so was not adequately monitored.”

Expert Opinion
"This is a tragic case in which a man died due to multiple failures in care by the very organisation responsible for protecting him whilst he was vulnerable.

“Feeling suicidal is a temporary state of mind; if appropriate and timely care is provided to people who are experiencing deep unhappiness and distress, this can diminish the risk of them ending their own life. The necessary care was not provided in Rory’s case and he and his family have been severely let down.

“Rory’s family are pleased that the Trust has admitted responsibility for Rory’s death and hope that steps will be taken to improve the standard of care provided to mental health patients to prevent cases like Rory’s from happening again.

“Rory’s inquest comes just a couple of weeks before Mental Health Awareness Week and highlights important lessons which need to be learnt about patient safety in a mental health context.”
Georgie Cushing (Nee Kerr-Dineen), Solicitor

 Rory’s wife Anita said: “Rory was completely let down by those who were supposed to be keeping him safe and I am still trying to come to terms with what has happened.

“As a family we have lost a loving husband and father because of inadequate care, policies and procedures which jeopardise the safety of vulnerable people.

“We are grateful to the Coroner for conducting a thorough inquiry and hope that the Trust will pay heed to the shortcomings identified in their own investigation report.

“We will continue to work with our team at Irwin Mitchell in order to get justice in Rory’s memory and to ensure that no other families go through what we have over the past two years.”

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

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