Call For Lessons To Be Learnt From Tragedy

The distraught family of a 48-year-old man who was found hanged 24 hours after he absconded from a psychiatric hospital heard at an inquest today how he had been allowed to walk out of the ward completely unnoticed by nursing staff.

Dr Timmins, Mr Fagan’s psychiatrist, told HM Coroner for Northamptonshire, Mrs Anne Pember that former cub-scout leader, Ronald Fagan, from Towcester in Northamptonshire had a long history of mental health problems and was suffering with severe depression.

Despite being ‘sectioned’ under the Mental Heath Act just six days earlier, after attempting to jump from a motorway bridge, Mr Fagan had been  placed on an un-locked ‘open’ ward at Northampton’s Berrywood Hospital and, on 29th  October 2010, he was able to abscond from the unit unchallenged by staff.

The following day, on 30th October 2010, the body of the father- of-two was found by a dog walker, hanged from a tree in a nearby field.

Following a verdict today that Mr Fagan had killed himself whilst the balance of his mind was disturbed; a medical law solicitor from Irwin Mitchell Solicitors says the hospital must urgently learn lessons from this tragic death in order to safeguard the welfare of other vulnerable patients.

The inquest heard that two weeks before Mr Fagan’s death, he was discovered in his car, parked in a lay-by. He was taken to Northampton General Hospital and it was discovered that he had taken an over-dose of prescription medicine. A suicide note was found in the car stating that he wanted to end his life.

Mr Fagan was discharged but the following day he was informally admitted to Berrywood Hospital (formerly known as the Pendered Centre.)

Six days later, Mr Fagan absconded from Berrywood Hospital and was found by police on a motorway bridge. Officers managed to stop the traffic below and Mr Fagan called off his threats to jump. He was returned to Berrywood Hospital and was briefly sectioned under the Mental Health Act.

On 26th October 2010, Mr Fagan’s wife, Dianne, visited him in hospital and became concerned when she found blood on his sleeve. She alerted hospital staff, when she discovered that Mr Fagan had managed to harm himself with sharp metal from a drinks can.

When Mr Fagan absconded for the last time on 29th October 2010, his family was only informed when his wife called the hospital to check on his condition. She was horrified to learn that he had called the hospital to say he was in a field and had a rope with him.

On 30th October 2010, following a desperate wait for news, Mrs Fagan was visited by a police officer to confirm that her husband had been found hanged from a tree.

Mr Fagan, a self employed decorator, had been married for 20 years and leaves behind two children, Alex (19) and Charlotte (18).

Christopher Hurlston, a medical law solicitor from Irwin Mitchell Solicitors, who is representing the family, said: “We are grateful to the coroner for investigating Ron’s death and whilst the family feel that they received many answers, they still have important questions regarding the standard of care he received whilst at Berrywood Hospital.

“It is clear that Ron was very vulnerable and, following previous attempts to harm himself, it should have been apparent that he needed very close supervision and constant monitoring. Given the fact that his mental health had warranted him being formally sectioned, his family are appalled that just days later he was still placed on an open ward and simply allowed to walk out of the hospital unchallenged.

“We understand that since Ron’s death, the ward has changed from an ‘open’ to ‘locked door’ status, a move which sadly has come too late to prevent Ron’s tragic and untimely death.  The Fagan family also has serious concerns regarding staffing levels in the unit and, in particular, the amount of time that staff physically spent with patients on the hospital ward.”

Dianne Fagan commented: “Ron meant the world to us. Although he had a long history of depression, he always tried to live a full life.

“His death has had a devastating effect on the entire family, especially our two children Alex and Charlotte, who miss him so much.”

 “Ron was well known locally and played a big part in our community. He maintained the Christmas lights that were put up every year in Towcester village. He was also a leader in the local cubs group and used to help run Towcester Youth Coffee House, a youth club for children, which has sadly had to close down since his death.”

Christopher Hurlston added: “We are now calling for the hospital to prove that it has learned lessons from this appalling tragedy, to ensure that the welfare of other vulnerable people is fully safeguarded.

“Following today’s inquest the family will be considering its options, including the possibility of civil action against the Trust.”

Our medical negligence lawyers can help if you have lost a loved one due to a preventable suicide caused by mental health care failings. Visit our Failure To Prevent Suicide Claims page for more information.