The death of a 54-year-old man who deliberately walked in front of a lorry on the A14 has led to “numerous changes” in procedure between two NHS trusts, an inquest heard.
Andrew Gibbins, who had a long history of “complex” mental health issues, was hit by a heavy goods vehicle on the westbound carriageway shortly after 8pm on January 15, Suffolk Coroners’ Court heard.
Mr Gibbins, who was an informal patient at Wedgwood House mental health unit in Bury, which is located on the West Suffolk Hospital site, had previously stepped in front of vehicles twice before on January 4 and January 12, the inquest heard.
On January 15, Mr Gibbins had been allowed to leave the hospital site unescorted for a cigarette break, which he had done so on three occasions between 7pm and 7.30pm.
He had previously been escorted on his cigarette breaks during the day but after 5pm, it was decided that escorted breaks were no longer required given the earlier breaks had passed without incident, the inquest heard.
Giving evidence on the second day of the inquest, mental health charge nurse Belinda Warby said she enjoyed a good relationship with Mr Gibbins and that he was open and honest with her.
She said multiple risk assessments had taken place and it would not be unusual for Mr Gibbins to go out several times a day for a cigarette.
The inquest heard that Mr Gibbins had been escorted to the Acute Assessment Unit (AAU) at West Suffolk Hospital from Wedgwood House for tests around 7pm and a handover took place.
During one cigarette break that evening, Mr Gibbins was escorted back to the hospital by a security guard and told him he was feeling suicidal in “a general way”.
When returning Mr Gibbins to the hospital, information provided by the security guard did not reach the AAU lead nurse or anyone from Wedgwood House, the inquest heard.
Jacqueline Devonish, area coroner, said this “could have been a missed opportunity to support Mr Gibbins”.
MORE: Man killed in lorry collision on A14 had ‘complex’ mental health issues, inquest hearsThe inquest heard a joint serious incident review had been undertaken by the Norfolk and Suffolk NHS Foundation Trust and the West Suffolk NHS Foundation Trust, and had led to a report which recommended changes to policy.
Ms Devonish added that “numerous changes” had already been made to procedure following the report and the trusts were now “working more closely”.
The medical cause of death was recorded as multiple injuries as a result of the road traffic collision, and a verdict of suicide was recorded by the coroner.
In a family statement, Mr Gibbins’ mum and sister, Jean and Julie Gibbins, said their loss and the circumstances had been “extremely hard to bear”, but they were relieved that recommendations had been made to “close loopholes in the system”.
They said: “We have always believed that Andrew’s tragic death could have been avoided if greater care was taken to supervise, reassure and stay with him during and after his visit for tests to the main West Suffolk Hospital from the mental health ward on January 15, 2020.
“We would like to thank all individuals who have worked so hard to produce a report which recommends changes to mental health care in the future, we are also extremely grateful for the kind and compassionate help we received from the police liaison officer throughout this difficult time.”
Diane Hull, chief nurse at Norfolk and Suffolk NHS Foundation Trust, said: “Our hearts go out to Mr Gibbins’ family and we are keen to support them in any way we can.
“Norfolk and Suffolk Foundation Trust and West Suffolk NHS Foundation Trust looked together at the care given to Mr Gibbins, and as a result have taken measures to ensure teams work more closely with each other in the future.
“Tragically suicide still affects and takes far too many lives. We are working with partners across health, social care and the voluntary sector to do all that we can to avoid the loss of life from suicide.”
A spokesman for West Suffolk Hospital said: “These were tragic circumstances and we offer our condolences to Mr Gibbins’ family. We will, of course, carefully consider the coroner’s findings and make changes where necessary.”
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