‘Shocking’ failures by mental health unit led to Ken’s suicide, says coroner
WIDOW’S ‘DISBELIEF’ THAT HE WAS ALLOWED UNESCORTED LEAVE
THE widow of a man who took his own life was left in “disbelief” by a mental health unit’s decision to give him unescorted leave.
Ken Baylis, who was in a “deep depression” and had a history of suicide attempts, died after stepping in front of a bus on January 23 last year.
An inquest found the decision by Millbrook Mental Health Unit to allow the 67-year-old to leave two weeks earlier should not have happened, with the coroner criticising staff for not involving his family in the discussion.
Mr Baylis’s wife of 40 years, Sally, said the lack of communication left her with “no clue what was going on”.
Nottinghamshire Healthcare Foundation Trust (NHFT) said it was “deeply sorry” for the shortfalls in his care.
Mr Baylis, a retired personnel officer who lived in Mapperley Park, began struggling with depression in 2021, trying to take his own life in November that year.
“It was like dark clouds had descended over him – it was very sudden,” recalled Mrs Baylis, who described him as a “funny and very kind man”.
He attempted suicide two more times on either side of a stay at Highbury Hospital in the summer of 2022.
The latter saw Mr Baylis try to jump out of a car on the motorway, which his wife said was an “incredibly frightening” experience.
“He opened the door to get out on the fast lane of the M1 when I was driving one night,” she said.
Mr Baylis was admitted to Millbrook as a voluntary patient on December 28, 2022, shortly afterwards. Mrs Baylis received no communication from the hospital in the following weeks, even when her husband was allowed to go on unescorted leave on January 10.
“When I saw him the following weekend he said he was being allowed out on his own. I thought that couldn’t be right. I was all at sea, I hadn’t a clue what was going on.”
When Mr Baylis died, his wife said she was “in disbelief that he had been out on his own near a road”, but convinced herself it was an “unfortunate accident”.
“It was easier,” she added. She became suspicious at a meeting with the care team.
“I wanted to know how he was, so I knew how he was feeling on his last day, like if he was smiling,” she recalled.
“But I realised something had gone wrong because no one was very open.”
The inquest at Nottingham Council House found there was a “serious underestimation” of his “real and imminent” risk of suicide.
This included an “inadequate and incomplete” risk assessment which was “severely compromised” by the fact the family had not been contacted.
“His repeated reporting of lack of suicidal thoughts, and intentions was not adequately challenged,” said assistant coroner Elizabeth Didcock.
She said the decision to allow Mr Baylis to leave “should not have occurred”, adding: “Had there been family involvement in the decisions regarding leave arrangements, had there been greater weight given to the repeated, and very recent, very serious suicide attempts, together with more direct involvement requested of the specialist depression service, it is unlikely that this incorrect decision would have been made.”
Ms Didcock said the failures made a more than minimal contribution towards Mr Baylis’ death. She pointed out that staff failed to follow trust policies regarding family involvement in his care, something Mrs Baylis said was “shocking” to hear.
“We were hoping he could get back to being that man who enjoyed life again,” she said. “He had the intention of killing himself but if he’d have been kept safe I think he would have come through that because he had come through it before.”
NHFT chief executive Ifti Majid said: “On behalf of the trust, I once again extend our sincere condolences to Kenneth’s wife, his family and friends for their loss. We acknowledge there were aspects of care which were not of the quality they should have been and, for that, we are deeply sorry.
“We recognise the importance of listening to families and involving them in decisions about their loved one’s care and will continue to focus on this as a priority area.”
Ms Didcock issued a prevention of future deaths report outlining her concerns regarding Mr Baylis’ death. NHFT has until April 29 to respond with an action plan.
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