Man killed himself after hospital sent him home

ACORONER has urged a Black Country hospital to take action after a pensioner took his own life less than an hour after being sent home due to a lack of psychiatric beds.

Colin Johns was admitted to New Cross Hospital A&E on March 11, telling staff he had been drinking and felt suicidal.

But after a mental health assessment the 71-year-old was sent home alone because no bed could be found for him at Penn Hospital in Wolverhampton, for inpatient mental health treatment.

During a mental health assessment he asked to be admitted to a psychiatric ward telling the practi- tioner he would ‘jump out the window’ or ‘cut his wrists’ if he was sent home. Mr Johns was discharged at 2.30am the next morning under the care of the home treatment team, but less than an hour later took an overdose of paracetamol.

He was found by a nurse the following morning and eventually taken back to hospital, after a two hour delay by paramedics. He died later that day. Now it has emerged that two beds were available at Penn Hospital, run buy the Black Country Partnership NHS Trust, at the time that Mr Johns asked to be admitted.

At the inquest of Mr Johns in June the coroner concluded that Mr John’s death had been a suicide contributed to by neglect.

Now Black Country Coroner Zafar Siddique has written to the Trust urging them to take action in a report to prevent further deaths.

The report published on August 14 said: “There were failures to accurately take his full history as part of the risk assessment and the mental health team staff were unaware of the fact he had attempted to strangle/suffocate himself whilst in the A&E department.

“In addition he had tried to gain access to the drugs trolley whilst in the A&E department.

“Whilst a number of attempts were made to secure an older adult inpatient bed, there is no documented evidence that consideration was given to locate a younger adult inpatient bed for the patient and the MHLS Practitioner was unable to recall if this was considered.

“It has since been ascertained that on the evening in question, there were two vacant male beds on Brook ward Penn hospital.”

The coroner stated that further efforts should have been made to find Mr Johns a bed, as he was clearly at high risk of harming himself.

He outlined actions he believed should be taken by the Trust, which included communication between the mental health liaison and the hospital, and reviewing the guidance in place to manage patients at significant risk.

A spokeswoman for the Black Country Partnership NHS Foundation Trust said: “The Trust is currently responding to the Coroner’s request, and as such is not in a position to provide information at this point.”