Family lost loving father due to ‘inadequate care’

Coroner rules suicide risk patient ‘not adequately monitored’

HILLINGDON Hospital has admitted liability for a patient who committed suicide while his nurse went on a break.

Rory Magill, 44, was left unattended despite being a known suicide risk, having gone to A&E because he tried killing himself by swallowing antifreeze.

Hillingdon Hospitals NHS Foundation Trust, which runs the hospital in Pield Heath Road, has now accepted responsibility for a string of failings in his care.

The father-of-four’s widow, Anita Magill, 43, of St Helen’s Close, Uxbridge, is calling for lessons to be learned from the tragedy.

She said: “Rory was completely let down by those who were supposed to be keeping him safe and I am still trying to come to terms with what has happened.

“As a family we have lost a loving husband and father because of inadequate care, policies and procedures which jeopardise the safety of vulnerable people.” Selfemployed electrician Mr Magill was admitted to A&E on June 12, 2013.

The hospital did not have the usual drug antidote needed to treat his antifreeze poisoning, so Mrs Magill was sent out to buy alcohol – an alternative treatment. Mr Magill was prescribed 500ml of vodka and one strong beer per hour, despite being known to have had alcohol problems.

Shortly afterwards, a psychiatric liaison nurse assessed Mr Magill, deeming him to be at a medium-to-high risk of suicide and self-harm and recommending he receive one-to-one observation.

A registered nurse was assigned to his care, but was soon asked to observe a second patient, who was being disruptive.

At 4.40am the next day, the nurse went on her break and did not hand over Mr Magill’s care to another nurse, leaving him free to wander the unit unattended.

He went to the toilet and returned and then had a conversation with a nurse. This nurse considered he was attention seeking.

Soon afterwards, Mr Magill requested a cup of coffee and asked whether there was somewhere else he could sit because he was having “lots of thoughts”. The nurse said he could sit in the day room, which he did, unattended. He later returned to his bed while the nurses went about their duties.

At approximately 5.45am, at least 15 minutes after he had last been seen, the nurses noted Mr Magill missing and searched for him.

He was found hanged in the day room and, despite resuscitation attempts, was pronounced dead at 6.40am on June 13, 2013. Following Mr Magill’s death, Mrs Magill instructed specialist medical negligence lawyers at Irwin Mitchell to investigate her husband’s care. She is now suing the trust.

Meanwhile, the trust carried out an investigation and prepared a serious incident report, which found there had been a series of failings.

The trust’s report concluded that the root cause of Mr Magill’s death was suicidal ideation and intent with no one-toone observation at the time of the event.

At an inquest held at West London Coroner’s Court on April 28, HM senior coroner Chinyere Inyama record the narrative conclusion: “Mr Magill took his own life, in part because the risk of him doing so was not adequately monitored.”

A trust spokesman said: “The Hillingdon Hospitals NHS Foundation Trust has carried out a thorough investigation into this incident and has cooperated fully with the Coroner’s enquiry. The Trust would again like to offer its sincere condolences to Mr Magill’s family.”