Man Took His Own Life 48 Hours After NHS Staff Determined He Wasn’t A Suicide Risk
A father from North Yorkshire, whose son took his own life 48 hours after hospital staff determined he wasn’t a suicide risk, is calling for lessons to be learned after he received an apology from the NHS Trust.
Andrew Bellerby, who was living in Upperthorpe, Sheffield, arrived by ambulance at the A&E department at the Northern General Hospital on 8th July, 2015 after being referred by a pharmacist who was concerned for his health and wellbeing. Andrew informed staff that he was experiencing suicidal thoughts, had made superficial cuts to his wrists, and was threatening to jump from a fifth floor window.
Andrew was referred to the Liaison Psychiatry Service, where he was seen by mental health nurses. Andrew informed the nurses that he had made several suicide attempts in the previous week including an attempted heroin overdose, hanging and thereafter asphyxiation. Andrew also informed the nurses that he had a history of substance abuse and the he didn’t feel safe and felt mentally unwell. The nurses were aware that Andrew was already receiving treatment for anxiety and depression.
A Crisis Triage Rating Scale (CTRS) was used by the nurses on admission, and Andrew was scored as 14 out of 15. He was discharged from hospital. A score of nine or less indicates a person may require hospital admission whereas a score of 14 or 15 indicates a non-urgent issue. The internal investigation by the Trust found that the nurses who carried out the CRTS assessment had no training in doing so.
Less than 48 hours later, Andrew hung himself and died on 10th July, aged 35. He had a suicide note in his pocket.
After Andrew’s death, his father Richard Bellerby, aged 72 living in Aldwark, instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the circumstances surrounding Andrew’s death, and the care he was given.
Richard, a former company director, said: “Andrew’s death was devastating for the family. It’s been a difficult three years as we have tried to come to terms with his death.
“The experience has left us feeling that our son’s life was worth nothing to the NHS and those responsible for Andrew’s care. That is an unbearable and unacceptable feeling.”
An inquest into Andrew’s death conducted in October 2015 identified numerous missed opportunities to provide Andrew with psychiatric help. The Sheffield Health and Social Care NHS Foundation Trust, the Trust responsible for Liaison Psychiatry Service, has also conducted an internal investigation into Andrew’s death and apologised to Richard, but has denied liability for Andrew’s death.
The apology only came, after settlement of the legal action against the Trust and even then after a prolonged delay.
Richard added: “The inquest was a difficult experience. Andrew’s own GP failed to prepare for the inquest; he didn’t bring any of Andrew’s medical records or notes and consequently struggled to answer any of the Coroner’s questions.
“The grieving process has been made worse and intensified by the fact we have had to deal with numerous unnecessary issues and delays throughout the legal process, such as the loss of some of Andrew’s medical records in off-site storage which further delayed the process. But this is just one of a number of things that have troubled us.
“At the conclusion of the legal claim I was initially told that a formal apology from the Trust would not be provided rather I would have the opportunity to meet with the Head of Corporate Affairs to discuss what had gone wrong in Andrew’s case, to discuss the changes that had been made and to hopefully prevent other families having to go through what we have.
“However, the offer of a meeting was subsequently withdrawn and a formal apology offered instead from the Trust. After two months and repeatedly chasing the Trust the apology letter was eventually received but it wasn’t a sincere or sympathetic apology for the loss of our son, it was more like a formal business letter from the Chief Executive. It felt like something that had been rushed to his desk, and taken off as soon as he signed it. That’s how little Andrew’s life had been worth to them.
“These experiences all add to the pain that we as a family have felt since losing Andrew. We wanted some justice for him, to do right by him and more importantly to try and prevent the same thing happening to another person in need.”
Samuel Hill, the medical negligence specialist at Irwin Mitchell’s Leeds office representing Richard, said:
Expert Opinion“What Richard and the rest of the family have gone through is heart-breaking and the issues highlighted by the Trust’s own internal investigation are concerning.
“Andrew was a vulnerable person, who went to seek help from those we put our faith in to give us that help. Unfortunately, he was deemed to be in a position where the help was not urgently needed.
“The Trust’s report into Andrew’s death identified six recommendations to be implemented to ensure the same thing doesn’t happen again. We implore the Trust to ensure these recommendations are implemented fully and that the lessons are fully learned to prevent another family suffering the way that Richard and his family has.” Samuel Hill - Partner