NHS Admits Suicide Of High Risk Patient Could Have Been Avoided

Specialist Medical Negligence Lawyers Call For Action To Implement Report Recommendations

07.05.2015

Dave Grimshaw, Press Officer | 0114 274 4397

A North West NHS Trust has admitted that a man being treated for depression and flagged as a high suicide risk may not have died had they not made failures in his care leaving him able to buy alcohol and hang himself on a wardrobe which was identified as a danger almost a year before his death.

Frank Galloway died aged 55 in October 2010 at Moorside Ward, Rochdale Psychiatric Unit. He was admitted to the psychiatric unit because of an attempted suicide after he became depressed following chemotherapy for throat cancer.

His family instructed specialist medical negligence lawyers at Irwin Mitchell to investigate his death as he was supposed to be observed every 15 minutes yet on the day he tried to take his own life he had been able to buy and consume alcohol and hang himself on a wardrobe. The family and their expert lawyers are now calling on the NHS to implement recommendations made in a report to improve care for the future.

The Pennine Care NHS Foundation Trust responsible for the unit admitted that Frank would probably not have died if they had not breached their duty of care.  An Incident investigation report by the NHS Trust after his death made 15 recommendations and identified multiple failures including:
• Not carrying out and managing an appropriate risk assessment during his admission
• He was on the ward for over a week without a comprehensive assessment of risk
• Allowing him to leave the ward alone despite him being listed as on 15 minute monitoring intervals
• A failure to remove a wardrobe door which had been identified almost a year earlier as a hanging risk.

An Inquest held in January 2012 recorded a narrative verdict saying that Frank took his own life in part because precautions were not taken to prevent him doing so. The coroner added that Frank was being treated for depression and was under the influence of alcohol which may have contributed to his state of mind.

Expert Opinion
“This is an extremely tragic case in which a man died because of multiple failures by the same organisation who were supposed to protecting him while he was so vulnerable.

“The family was heartbroken at his death, but were even more distraught when they found out his death could have been avoided.

“They are relieved that the Trust has admitted responsibility and that several investigations, including that at the Inquest, have examined the incident and recommended changes to protect others in future. Patient safety should be the number one priority but in this case Frank and his family were severely let down.”
Ayse Ince, Associate

Frank was also the carer and husband of Margaret Galloway who lived in Failsworth.

Sarah Galloway, Frank’s daughter, said: “Nothing will ever bring Frank back and we are still so upset by what happened. We thought, as Frank did, that he would be safer in the hospital until his condition improved but sadly that wasn’t the case.

“We just hope that the Trust will make the necessary changes to prevent this ever happening again as we wouldn’t want anyone to go through the emotions we have experienced over these past few years.”

Background

Frank had treatment for throat cancer in 2009 which required chemotherapy and he had begun drinking heavily to deal with the diagnosis. On 10 October 2010 he was admitted to Oldham A&E after a medication overdose taken with alcohol. A few days later on 12 October an ambulance was called to his home because of another overdose on mixed medications and alcohol and Frank had expressed a wish to die.

He was reviewed by a senior psychiatrist who recorded that Frank was likely to try suicide again if he was left alone and that he had agreed to a voluntary admission to the Moorside Ward at Rochdale Psychiatric Unit Hospital.

On admission it was noted that he was a high risk of suicide and recommended to be observed at 15 minute intervals. However on the 22nd October he went to a local shop without medical supervision – a trip which lasted longer than 15 minutes – and was seen to buy whiskey. This wasn’t confiscated despite the hospital having a policy to check a patient’s possessions on their return.

Later that day another patient found Frank hanging from a wardrobe door on a dressing gown cord which had also not been removed from his possession. Emergency care was given over the next few days but treatment was finally withdrawn on 26 October and he died.

An earlier audit of the room in December 2009 had identified the wardrobe door as a potential hazard but it had not been changed while an inspection of Frank’s room also found that the shower rail had collapsed which was indicative of an earlier attempt on his own life.

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.