Widow’s Hope That Others Don’t Have To Suffer Pain Of Her Family

A widow has urged health bosses to learn lessons after her husband, who had a history of mental issues, was found dead the day after walking out of a hospital.

Gideon Tranter’s family had wanted the 49-year-old detained under the Mental Health Act after he was admitted to Bath’s Royal United Hospital with deep cuts to his wrists and an abdomen injury. Police had found Gideon in the same field where his twin brother had taken his own life several years earlier, an inquest heard.

Following his death, Gideon’s family instructed medical negligence experts at Irwin Mitchell to help investigate the care the father-of-two received at the hands of Avon and Wiltshire Mental Health Partnership NHS Trust and Royal United Hospitals Bath NHS Foundation Trust.

Four days after he was admitted to hospital he was deemed medically fit to be discharged. Following pleas from wife, Clare, Gideon was due to undergo a mental health assessment the following day.

However, he went missing from the ward that night after medical staff told him about the assessment against his wife’s wishes. Police found his body in the garden of a house in Bath the following day.

Coroner Dr Simon Fox, QC will now ask the health trusts to review their practices around mental health.

It comes after the inquest heard that forms used to assess Gideon when he arrived at Royal United Hospital’s A&E department did not include a prompt for staff to speak to relatives or carers about a patient’s mental health history. Paperwork also did not include a section confirming a mental health assessment had been completed, leading to confusion over whether Gideon had been referred for an assessment, the hearing heard.

Dr Fox, who recorded a narrative verdict, also advised Avon and Wiltshire Mental Health Partnership NHS Trust that surgery or waiting for a patient to complete alcohol detoxification should not be reasons for delaying a mental health assessment.

Expert Opinion

This is an incredibly tragic case and, many months after Gideon’s death, Clare and the rest of the family remain understandably devastated by the loss of a much-loved husband and dad.

“Some of the evidence heard during the inquest has revealed some areas of concern and we hope that these will be addressed as soon as possible to improve patient safety.

“We will continue to work with Clare to ensure she, and the family, receive the right support.” Elise Burvill - Associate Solicitor

Gideon had been married to Clare, 47, for 17 years and the couple, who lived in Radstock, Somerset, had two children, Jack and Emma, aged 17 and 14. Gideon and Clare ran a family removals business.

An inquest at Avon Coroner’s Court was told that Gideon, who was receiving help to try reduce his alcohol intake, first become known to mental health services in May 2013.

He had tried to take his own life twice previously, including in October 2016. While recovering in Royal United Hospital he managed to walk out of the grounds and was taken back to hospital by police, the hearing was told.

On 1 June, 2017, Gideon had been missing all day. Police found him injured in a field in Writhlington, taking him to hospital.

Clare asked the hospital to place her husband on a secure ward as he was likely to escape, the inquest was told.

The court heard that on 5 June Clare pleaded with Avon and Wiltshire Partnership for Gideon to be assessed as she was told her husband was medically fit to go home.  A formal mental assessment was scheduled for the following day but Gideon left the ward.

At around 10pm Clare spotted Gideon near the hospital when driving looking for him. However, by the time it was safe to pull over and alert the hospital, he had vanished.

Police found his body at around 8pm on 6 June. It’s believed he had fallen 15 feet after climbing railings.

Dr Richard Badcock, consultant forensic psychiatrist, said he did not see why Gideon’s mental health assessment had to be postponed until after surgery on his wrist injury.

Informing Gideon, who was ‘good at concealing his mental state’ of his pending assessment was a ‘significant factor’ in his decision to leave hospital, Dr Badcock added.

He also said that if a member of hospital staff had taken responsibility for Gideon’s overall care 'the outcome may well have been different.’

After the hearing Clare said: “This horrible illness is indiscriminate and anyone can be affected by mental health issues.

“Family life had become difficult and that’s why we wanted Gideon to receive the help he so dearly needed.

“We feel that the response by the health trusts was not adequate especially in light of our concerns about Gideon’s history of leaving hospital and being able to hide his mental state.

“Staff seemed to be more concerned about Gideon’s physical injuries and not his mental state. We feel that there were unnecessary delays in assessing Gideon. Had he been assessed earlier Gideon could have been detained, would not have left hospital and so would not have died, meaning our family could be looking towards the future and not struggling to come to terms with his death .

“Our only hope now is that the heartbreak our family has suffered highlights the need for those with mental health issues to receive swift treatment.

“We hope that the Trusts continue to learn from the issues which have been highlighted at inquest to ensure other families are spared the pain we have to endure on a daily basis.”

Read more about Irwin Mitchell's expertise in handling medical negligence cases.