Essex psychological well being belief neglectful over demise, coroner says

A psychological well being belief was neglectful in its conduct when a affected person died two days after being admitted to hospital, a coroner has stated.

Stephen Neville, 68, died on Beech Ward at Rochford Community Hospital which is run by Essex Partnership University NHS Foundation Trust (EPUT).

A prevention of future deaths report was issued to the belief following a nine-day inquest which discovered a “series of serious failings” contributed to his demise.

Paul Scott, chief government at EPUT, stated: “My deepest sympathies remain with Stephen’s family, friends and loved ones and I would like to apologise for the failings in his care.”

Essex space coroner Sean Horstead concluded on the inquest, which passed off in October, that Mr Neville’s demise was “contributed to by neglect”.

He was discovered lifeless on the hospital on 18 December 2021, having taken his personal life, after being admitted as an inpatient two days earlier.

In the report, published on Wednesday, the coroner stated: “His direct admission had bypassed the trust’s usual referral, gatekeeping and bed management processes, contrary to trust policy.”

An affiliate specialist psychiatrist undertook a scientific evaluate the day after he was admitted and had been unaware Mr Neville was prescribed each day Lorazepam in the neighborhood for about 14 months – alongside antidepressant remedy.

Mr Horstead discovered there have been “failures to identify and communicate up-to-date risk assessments” between psychological well being groups.

He additionally stated workers “failed to engage with family members” to hunt info related to Mr Neville’s danger.

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The coroner concluded there was “failure to appropriately manage the unlocked shower room” the place he died and to “mitigate the clear risks” of his unsupervised entry to the room.

He was frightened about workers not observing sufferers effectively sufficient and was involved concerning the “quality of the conduct of the EPUT staff of such critically important observations” concerning “highly vulnerable inpatients at risk of suicide”.

EPUT stated it had invested £20m into their wards to enhance security.

BBC East’s well being correspondent, Nikki Fox, stated EPUT had acquired not less than 4 neglect findings from inquests this yr: Darren Turner, Abbigail Smith, Elise Sebastian and now Stephen Neville.

“These tragic deaths may have happened a number of years ago, but in June 2021, before Mr Neville’s death, Mr Scott said he was committed to doing everything he could to ‘ensure EPUT provides the safest possible care’,” she stated.

He was talking after the belief was fined £1.5m over 11 patient deaths, and for breaching well being and security legal guidelines surrounding ligatures in its models.

EPUT is the topic of a public inquiry examining more than 2,000 deaths of psychological well being sufferers.

Fox continued: “The number of neglect findings and prevention of future death notices issued by coroners in relation to the trust is not reducing. This has to be of concern to the Lampard Inquiry, which has said it is monitoring inquests.”