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Coroner calls for changes after bridge suicide

PUBLISHED: 09:00 16 May 2008 | UPDATED: 19:21 10 March 2010

Stephen Woodruffe

Stephen Woodruffe

A CORONER has asked mental health bosses in Suffolk to review their procedures after a schizophrenic jumped to his death off the Orwell Bridge - days after his pleas to be admitted to hospital were rejected.

A CORONER has asked mental health bosses in Suffolk to review their procedures after a schizophrenic jumped to his death off the Orwell Bridge - days after his pleas to be admitted to hospital were rejected.

Stephen Woodruffe, 28, took his own life on June 9 last year after becoming depressed and withdrawn, an inquest at Ipswich Crown Court heard yesterday.

The degree student, who was on medication to control his schizophrenia, had sought the advice of his GP over an alcohol problem and was referred to the local Norcas drugs charity on June 5 to receive help.

While there, drugs worker Sam Lockwood became concerned when Mr Woodruffe told her he had not taken his schizophrenia medication for two weeks and was on the verge of a psychotic episode.

Ms Lockwood contacted St Clements Hospital in Ipswich to alert health workers to his condition and Mr Woodruffe was put in telephone contact with community mental health nurse Sue Lindsay.

The student, of St Georges Street, Ipswich, told her he wanted to be admitted to the hospital but Ms Lindsay could not elicit any symptoms of psychosis in his voice.

After checking his history on a risk management plan, she decided not to admit him and instead he was given a 24-hour crisis number to call and his GP was contacted, the inquest heard.

But just four days later motorists spotted Mr Woodruffe “vaulting” over the side of the Orwell Bridge. He survived the fall and managed to drag himself to the bank but resisted attempts to resuscitate him.

Mr Woodruffe, who was described as an intelligent, shy and pleasant man, died later at Ipswich Hospital from bleeding into the lungs.

At yesterday's inquest, Greater Suffolk Coroner Peter Dean voiced concern that Mr Woodruffe had not been subjected to a face-to-face assessment of his condition and state of mind when he sought help.

“There are clearly issues around the ability to fully assess a set of circumstances on the telephone rather than physically seeing a patient,” he said. “It does appear his problems at the time did not seem to be related specifically to psychosis although he himself, knowing his condition, was worried he was about to become psychotic. Is that not enough information, given the history you're aware of, to trigger a face-to-face assessment to pick up not just the symptoms but also the signs?

“Everything comes down to a rather slavish following of the risk management plan. It appears not enough weight was given to what a colleague was actually telling you in respect of her concerns.

“His one attempt to get himself admitted to a hospital that, by his own admission, he didn't like very much was not even met with a mental health assessment. I think lessons need to be learnt about the way people approach these things.”

In recording a verdict that Mr Woodruffe took his own life while the balance of his mind was disturbed, Dr Dean asked Suffolk Mental Health Partnership NHS Trust to review its procedures and take on board the points raised.

After the inquest, Mr Woodruffe's mother, Susan Negus, said: “I appreciate the comments made by the Mental Health Trust that they will look to see in any way if there can be improvements.

“I was not aware as a member of the public that decisions regarding people being admitted to hospital were made over the phone.”

Norcas worker Ms Lockwood told yesterday's inquest that Mr Woodruffe had repeatedly told her he needed help and was worried he might end up hurting somebody.

“I was very anxious about what he was telling me. He was clearly saying he needed help and support,” she said.

The drugs worker contacted St Clements Hospital and as a result Ms Lindsay had a telephone conversation with the patient.

“He requested I admit him to St Clements Hospital but I told him I couldn't do this as he was not presenting any symptoms that were necessary,” said Ms Lindsay.

Speaking at yesterday's hearing, Robert Bolas, deputy chief executive and director of nursing at the Suffolk Mental Health Trust, said: “I am quite happy to give my commitment to the court and Mr Woodruffe's mother that we will review these procedures in more detail.

“We felt people acted in the best interests and believe Mr Woodruffe did not have a history of self-harm.

“It's not an exact science identifying an 'at risk' individual. The outcome was tragic but I have listened to the evidence and recognised we will need to look at our current systems again in terms of telephone evidence gathering.”

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