Patient found dead in canal after he left mental unit Staff ‘unaware of right procedures’ in second such tragedy, says coroner
ASOLIHULL man who was allowed to leave a mental health unit with no phone, money or coat while he waited 20 hours for a Mental Health Act assessment was found dead in a canal six days later.
Forklift truck driver Gary Parfitt was last seen alive on the morning on October 16 last year when he left the Oleaster Unit in Edgbaston, 11 miles from home.
Just a day earlier he had been taken to Heartlands Hospital A&E department after barricading himself and his brother into his Chelmsley Wood flat.
An inquest heard how paramedics and police were called on the morning of October 15 after the 41-year-old had become convinced drug dealers and a SWAT team had closed off the road.
Suffering from paranoia and delusions, he was taken to Heartlands Hospital where he was assessed by a RAID team, and a Mental Health Act assessment was requested.
Birmingham Coroner’s Court heard how Mr Parfitt was then moved to the Oleaster Unit at around midnight due to the A&E department “really struggling with winter pressures”. There, nurse Kay Hill said his mood fluctuated, and he continued to have hallucinations.
Frustrated by a total 20-hour wait, he told staff he wanted to go home at around 6am on October 16, leaving in just shorts and a T-shirt.
Staff failed to stop him butNurse Hill did ring police. However, Mr Parfitt never made it back to his flat.
Six days later, on October 22, his body was found in the nearby canal off New Fosse Way in Selly Oak.
Kerry Webb, nurse consultant at the Birmingham and Solihull Mental Heath Trust, told the hearing that Mr Parfitt should have never been moved to the Oleaster Unit.
There was a constant tension between deciding to detain someone and the freedom to leave, he said. He also admitted staff were unaware of the correct procedures, and did not know whether they could detain Mr Parfitt under the Mental Health Act.
Area Coroner Emma Brown said this was the second death she had encountered in six months where a delay in assessment had “materially contributed” to the death of a person.
“Is it your view that the people of Birmingham are being put at risk by the unavailability of an Approved Mental Health Professional to carry out assessment?” she asked Mr Webb.
He admitted resources were “incredibly stretched” and there were often delays in getting an assessment from Birmingham City Council’s on-duty team.
Ms Brown recorded a cause of death as drowning, with a secondary cause of alcoholic ketoacidosis, and came to a nar- rative conclusion: “Gary died as a result of drowning after collapsing from a physical illness and an incorrect decision to transfer him from acute hospital care in combination with serious insufficiency in efforts to stop him leaving the Oleaster Unit.”
She said she would ask the council to review the availability of mental health assessments.
The family has instructed lawyers and said they hope lessons have been learned by the Birmingham and Solihull Mental Health Trust.
Sister Cheryl Parfitt said: “We are always going to have questions, and we still feel anger about what happened.
“If he had got the care he should have done, and been assessed sooner, then he would still be with us now.”