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Man Who Committed Suicide After Walking Out Of Mental Health Facility was Victim Of “Insufficient And Inadequate” Standards Of Care

Matthew Llewellyn-Jones was able to leave his ward at Cedars Mental Health Unit in Exeter despite being detained under the Mental Health Act


A man who committed suicide after walking out of a mental health was a victim of “insufficient and inadequate” standards of care an inquest has concluded.

Matthew Llewellyn-Jones, from Sidmouth, Devon, was found hanged in the grounds of Cedars Mental Health Unit in Exeter on March 16 last year, just a day after being admitted.

The talented glass-blower had a history of mental health problems but had not been sectioned before when he was admitted to Cedars by his concerned mother, Roseanne, whom he feared aliens were trying to harm.

The 37-year-old’s family instructed expert medical negligence lawyers at Irwin Mitchell after it was found that Matthew had hanged himself after been able to walk out of his ward and leave the facility via the front door while he was supposed to be detained under the Mental Health Act and the ward was in lock-down.

A four-day inquest into his death, held at Exeter and Greater Devon Coroner’s Court, concluded on Thursday [October 13] that that there was insufficient assessment of Matthew’s risk of self-harm and absconding at both his initial assessment meeting on March 15 and the ongoing assessment meeting the following day, due to inadequate notice being taken of information available from family and other third parties.

Delivering their verdict of suicide, the jury told the coroner that they found that the level of contact received by Matthew, clinical notes and level of observation was insufficient and inadequate.

The jury found that Matthew’s ability to leave was a failure of the locked door policy at Cedars, and that patients going through the locked door into an unsecure area to smoke increased the risk that the locked door policy would fail. They added that they could find no evidence that Devon Partnership NHS Trust took all reasonable steps to reduce that risk.

Inadequate staffing levels were a contributory factor to failings at all stages of Matthew’s care and security, the findings concluded.

Coroner Lydia Brown acknowledged that much work had been done by the Trust to improve safety on the ward, immediately reducing the number of beds from 20 to 16 in the wake of Matthew’s death.

She said: “We are 18 months after the death and the Trust acknowledge and accept further breaches of that door, albeit without the same tragic outcome.”

The coroner said she remained concerned about the levels of observations at the facility and would use her powers under Regulation 28 of the Coroners’ Rules which seek to prevent future deaths, to advise the Trust to utilise technology so staff could see in ‘real time’ that observations had been made and not rely on paperwork.

Speaking on behalf of Matthew’s family, Chelsea Parkin, a specialist medical negligence lawyer at Irwin Mitchell, said: “Matthew was a man in the depths of crisis and was let down by those responsible for keeping him safe.

“His family too have been let down as they trusted that Matthew was in the best possible hands, only to lose him in circumstances which were entirely preventable.


“We thank the coroner for taking the time to examine Matthew’s final days and for recognising that Matthew was a man very much cherished by his family – a warm and creative person, full of character who tried to protect his family from the painful reality of his illness.


“We are also hugely grateful that Mrs Brown will be writing to the Trust invoking her powers under Regulation 28 to help prevent future deaths.


“While the details of his final days were incredibly distressing for his family to hear, the findings will now enable them to put this tragic end to his life behind them and focus on their memories of Matthew in happier times.

“We sincerely hope lessons can be learned from Matthew’s death in order to ensure that no other patient is allowed to slip through the cracks of the mental health service in this way.”


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