Settlement achieved for client who attempted suicide during unescorted leave from mental health facility
Amy* came to Irwin Mitchell’s medical negligence team after mismanaged psychiatric inpatient care resulted in a suicide attempt and catastrophic injuries during unescorted leave that should never have been authorised.
*Real name not used
Amy's story
Amy, an NHS speech and language therapist, is a married mother of three young children. Prior to the incident, she had a history of stress, anxiety, affective disorder, and bipolar disorder (in remission).
In 2022, her mental health significantly deteriorated, with repeated suicidal ideation and multiple suicide attempts requiring emergency and community mental health intervention. She was signed off work in April 2022, returned two weeks later, and was signed off again in June 2022.
She was ultimately admitted as an inpatient under mental health services due to high suicide risk.
Warning signs ignored
Initially, if Amy left the facility she was accompanied by staff, and she completed escorted walks to the local shop and as part of a walking group.
Throughout her time as an inpatient, Amy was consistently assessed as being a moderate to high risk to herself, and her symptoms showed little improvement.
A Care Programme Approach (CPA) meeting took place in December 2022, to discuss the prospect of home-based leave with supervision. Amy’s doctor noted that straight discharge to home was not favourable at that time and he recommended arranging home leave with her family before discharge, when she and her husband were ready for this.
The plan recorded at the end of this meeting was home leave with her husband for eight hours, unescorted leave to town for three hours, and unescorted leave for 30 minutes TDS (three times a day) in hospital grounds. However, there was no documented discussion or risk assessment supporting this decision, and both Amy and her husband state unescorted leave was never discussed with them.
Immediately after the CPA meeting, Amy had escorted leave with her husband in a café, where she expressed suicidal thinking and said that she was researching different suicide methods. These concerns were reported to staff, but there is no evidence that this information was escalated to Amy’s doctors.
Legal investigation
Amy enlisted one of our specialist medical negligence solicitors, Legal Director Louise Forsyth, to seek answers and accountability for what happened to her.
Our legal investigation focused on whether the NHS Trust breached its duty of care in managing a high-risk psychiatric patient, and whether that failure directly caused Amy’s injuries.
Louise obtained Amy’s medical records and instructed a Consultant Psychiatrist to provide a report on whether Amy’s care was negligent, which was supportive of our claim.
We asserted that:
- A proper risk assessment would have identified ongoing high suicide risk, and unescorted leave would/should not have been authorised.
- Had the husband’s report of the conversation in the café been considered by a doctor, the conclusion would/should have been that unescorted leave to the local area should be cancelled.
- Had Amy not been allowed unescorted leave to the local community, she would not have had the opportunity to harm herself, and her above-knee amputation and other injuries would have been avoided entirely.
Outcome and settlement
The NHS Trust initially denied liability and didn’t settle during the round table meeting (RTM).
In post-RTM correspondence, we reached a seven-figure settlement that recognises Amy’s permanent disability, ongoing psychological trauma, impact on family life, and need for lifelong rehabilitation and care support.
By reaching an agreement early on, we managed to avoid going to court, which would have delayed settlement and caused Amy and her family significant stress.
The settlement will enable Amy to purchase top quality prosthetics in the private sector and engage with physio and rehab services to improve her mobility and independence.
Expert comment
Amy’s solicitor, Louise, said about the case:
“This case demonstrates the importance of robust and documented risk assessment in psychiatric care.
“Amy and her family placed their trust in those caring for her. It is devastating that, at such a vulnerable moment, the systems meant to protect her fell short.
“Despite everything she has been through, she is now focusing on her recovery and taking positive steps to move forward with her life."
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