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NHS Should Have Done More To Prevent ‘Avoidable’ Suicide

Lawyers demand review into procedural errors after coroner finds vital information on the risk of suicide was lost by mental health services


Lawyers have demanded an urgent review of procedures at an NHS mental health trust criticised by a coroner over the suicide of a railway engineer whose repeated requests for help in the weeks before his death were ignored.

Peter Bane, 47, a senior engineer from Happisburgh, Norfolk, died when he was hit by both a passenger and a freight train on 16 February 2010. He was found with a suicide note in his pocket and had told Norfolk and Waveney Mental Health NHS Foundation Trust that he was contemplating taking his own life on at least three occasions in the two weeks prior to his death.

Now medical law specialists at Irwin Mitchell are calling for an urgent review of the way patients referred to psychiatric services are dealt after it was revealed that information on the severity of the situation was lost in the process of referral from GP to mental health services.

At today’s inquest today at Shire Hall, Chelmsford, Essex, HM Coroner Mrs McGann ruled that Mr Bane had killed himself whilst suffering disturbance of the mind. She heard how the standard procedure is for the GP to refer patients verbally to the mental health centre.  However, it transpired at the Inquest that these calls are not taken by mental health professionals; instead the calls are received by receptionists who have the responsibility of ensuring vital information is recorded. 

This information is then passed on to medical professionals to assess on a case by case basis. She said that vital information was lost between the GP’s call and the evidence passed to the medical staff on duty who were not correctly informed about the severity of the risk. Medical staff giving evidence also highlighted that the suicide risk appeared to have been underestimated by staff at the mental health centre.

Anita Jewitt, a medical law specialist from Irwin Mitchell representing the family, said: "Peter Bane was a hardworking, professional man who is sorely missed by his family and friends.  His family have suffered enormously over the past year and wanted the inquest to provide answers to their questions over the events leading up to his death.

“Peter and his wife Angela did all they could to seek out urgent assistance from the psychiatric services. Peter's GP responded to his pleas for help in the appropriate manner and referred him to mental health professionals. Unfortunately at this stage the loss of vital information has let the family down and is totally unacceptable.

“The evidence given regarding the circumstances of Peter's death was particularly harrowing and the consequences of the errors in this case will live with the family forever and they remain convinced that more could have been done to prevent his death. 

“The Coroner has suggested that she will be making written recommendations to the Trust to try and prevent further deaths and we welcome these steps. The family and I hope now that important lessons are learned by this Trust, and others, to improve the referral process from GP to mental health practitioners to prevent the same thing from happening again.

“Patient safety should be the number one concern of health professionals and the signs could not have been clearer that Peter was very worried that he would hurt himself.  If the mental health professionals had received all of the information, unfortunately it appears that Peter’s death may have been avoided”. 

The inquest heard how Mr Bane originally sought assistance from his GP on 5 February 2010 because he had suddenly developed very strong urges to commit suicide by walking in front of a train.  His GP assessed that he was at a "very high" risk of self harm and arranged for the psychiatric services to undertake an urgent assessment at Mr Bane's home.

This should have happened within the next four hours however, a home assessment did not take place and instead Mr Bane was telephoned by the psychiatric services. 

Mr Bane repeated that he felt unsafe at home and that he wanted to commit suicide by walking in front of a train. He repeatedly requested to be admitted to hospital but his requests were refused and he was advised that he only required a change in his medication.

Mr Bane attended the follow up appointment on 15 February and was given an increase in his medication, but no further action was taken in relation to a hospital admission.

He then went to work on the morning of 16 February but left shortly afterwards, and walked in front of a train with a suicide note in his pocket.

He leaves a wife and a 12 year old daughter.  He also had two adult children from a previous marriage.

His widow Angela Bane said: “We are devastated by Peter’s death. We knew he wasn’t well and had tried everything we could to seek out help.  I feel completely let down and angry. It is obvious that more should have been done to prevent his death. Peter did exactly what he said he would do and the mental health services have failed him.

“Peter had suffered from episodes of depression in the past, but we had battled through those times and he had been successfully treated and held down a very good job in London. There’s no reason why treatment would not have been effective on this occasion too.

“We can only hope that by highlighting our tragic case, lessons can be learnt so that others do not have to go through the same suffering that we have.”