Failings may have contributed to death of mental heath patient, jury concludes
PUBLISHED: 19:11 01 November 2018 | UPDATED: 09:54 02 November 2018
Failings at a mental heath ward may have contributed to the death of a 37-year-old patient, an inquest jury has concluded.
Matthew ‘Matty’ Arkle, of Cumberland Avenue, Bury St Edmunds, died on April 4 2017 while he was a volunteer patient at Wedgwood House at West Suffolk Hospital, which is run by Norfolk and Suffolk NHS Foundation Trust (NSFT).
Speaking following the hearing’s conclusion, his mother said she feels “let down by the people who were meant to be looking after him”.
A NSFT spokesman said it had undertaken a detailed review to learn lessons from the tragedy.
The four-day inquest heard Mr Arkle, who suffered from paranoid schizophrenia, was granted an hour’s unescorted leave from the acute mental health ward on the evening of April 4 despite his family telling staff they did not want him released.
The inquest heard the day before, his care co-ordinator Amanda Turner reported he was at “the lowest she had seen him in a long while”.
The jury heard this information was not passed on to the charge nurse, who granted his release.
Mr Arkle was found hanged in woodland on the grounds of the hospital two days later.
Giving a conclusion of suicide, the jury said although the circumstances around his release did not directly cause Mr Arkle’s death, failings at the ward may have contributed.
They identified failings in appropriate record keeping, in communication and a “general high level of activity and stress” on the ward. They also said staff’s delay in noticing, reacting and reporting Mr Arkle as missing and the timing of his release may also have contributed to his death.
Speaking after the conclusion, Matthew’s mother Sheila said: “We thought Matty was safe because he was in hospital.
“He was let down by the people who were meant to be looking after him. Nothing can bring Matty back, but if just one family could be spared of going through what we’ve gone through then there is a legacy for Matty.”
A spokesman for NSFT said: “The Trust has undertaken a detailed review to learn as much as possible from Matty’s passing and to implement positive improvements in its services, including the need to maintain full and accurate health records and to ensure that relevant information is handed over between shifts.
“In addition, nurse-led mental state assessments are undertaken when a service leaver requests leave and this information is recorded in a more structured way on a newly-introduced “Patient Leave Request Form”; staff have been released to spend more time “walking the floor” on our acute wards so that they are better placed to asess service users; and twice daily “safety huddles” take place where concerns about individual service users can be raised.”
Tim Deeming, a Partner at Tees Solicitors, who represented the family, said “This is not the first incident to have occurred at the Hospital Trust, and it must be devastating for families who have gone through a similar experience to hear of such repeated concerns.
“Given the evidence that has been heard and the jury’s findings it is heartening to hear that the Coroner will be submitting a Prevention of Future Deaths report so that effective lessons are learnt as widely as possible and similar circumstances avoided, taking into account the highlighted failures identified by the jury which were: failure of appropriate record keeping, failure of verbal and written communication, the general high level of activity and stress on the ward, the delay in noticing, reacting to and reporting Matthew as missing and the timing of Matthew’s release, being the late afternoon.”
Matthew Arkle’s sister Claire Huffer described her big brother as “a legend”.
She said he was central to their family, someone who “would always be there for you”.
“He was a legend,” she said.
“He was the most brilliant brother, uncle and son to all of us. He was just amazing, he will be missed.
“He loved his fishing, he loved his allotment and he loved walking his dog Hercules. He also loved the Green Light Trust in Bury St Edmunds, they helped him to do so many things he wanted to do.
“Despite his condition he would always be there for you.
“If you got to know Matty you for to see the cheeky chappy he was - taking the mickey out of grandad and things like that.
“He was always game for a laugh and always ready to have a laugh, when he was feeling okay.
“He was just a really good guy. He will be missed by us all.”