The family of a man who died while under the care of an acute mental health unit in Suffolk have settled out of court having brought legal action against the mental health trust.
Matthew 'Matty' Arkle, 37, of Cumberland Avenue, Bury St Edmunds, was found hanged on April 4, 2017, close to West Suffolk Hospital having been granted an hour's unescorted leave from Wedgwood House despite his family asking that he should not be released.
An inquest revealed failings at the unit, which is run by the Norfolk and Suffolk NHS Trust (NSFT), that may have contributed to his death.
Coroner Nigel Parsley wrote a Prevention of Future Deaths (PFD) report to the Trust following the inquest identifying failings in passing on the family's request to refuse leave, high levels of activity and stress on the ward and a delay in noticing Matty had gone missing.
Matty's sister Claire Huffer said she would be keeping a close eye on the Trust to make sure that progress had been made.
She said: "If they put into place what they say they are going to do that is good but every week you hear about another story about the NHS and mental health. There are still failings.
"Hopefully Matty's case has brought more families together to talk about mental health."
The Trust's response to the PFD report vows to address the concerns raised.
However, there were paragraphs identical to another response the trust had sent just weeks later in a similar case.
Mrs Duffer said the Trust need to investigate and respond to incidents on a case-by-case basis.
"It is not just about what is said, it is about how it is said," she said. "If there is the perception a PFD report is a process rather than looking at individual circumstances then there's the lack of engagement, awareness and understanding.
"When we first brought this forward I wanted an apology from the NHS, I know we won't get that apology. But if they put in place the things they said they will, we will be happy knowing if someone goes into their care they will be looked after properly.
"We hope Matty's death just hasn't been another death, just another percentage. But only time will tell."
Tim Deeming, at Tees Law who represented the family, said: " We remain concerned regarding the protection and supervision of patients at the Trust in the light of the inquest and other findings and would ask for reassurance that no other patient has left the unit in preventable circumstances since Matty's death, so that we know that effective lessons have been learnt from the tragic events and that there is an clear legacy for him"
The mental health trust's response
Pat Long, NSFT's Interim Deputy Director of Operations (Suffolk), said: "We would again like to express our most sincere condolences to the family of Matthew Arkle (known as Matty).
"Matty was well thought of by our staff and we were very sorry to hear of his death.
"The Trust undertook a detailed review to learn as much as possible from Matty's passing and to implement positive improvements in our services, including reinforcing the importance of maintaining full and accurate health records and ensuring 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'.
"Activity on a ward can vary from day to day, depending not just on the number of service users but also the level of care each patient requires at any one time. It is important that services can adapt to changing needs, so we have access to a pool of additional staff we can call in, in the case of emergency.
"We have also conducted a review into the staffing levels and skill mix on shifts to ensure we have the right staff, with the right skills in the right place at the right time."
Tribute to Matty
Matty's sister Claire described her brother was a kind-hearted "cheeky chappy" and hoped his legacy would be a more open public discussion about mental health.
"He was a gentle soul", she said. He was an amazing brother, uncle and son.
"Matty would do anything for anyone - his friends, family or just someone walking down the street.
"He was just amazing, you could ask him for anything.
"He loved the outdoors, he loved being in the elements and he loved fishing.
"He would be 40 next week and it is heartbreaking that he is not here with us.
"I just want people to talk more about mental health.
"If Matty's legacy does anything it is for people, especially men, to talk more about it and to get the support they need.
"We hope Matty's legacy will help save someone else's son, daughter, father or grandfather.
"As long as they learn from what has happened."
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