Tragic patient 'may have been failed'

A PSYCHIATRIC patient who hung himself in his hospital ward might have died because of failings in the health system, an inquest has revealed.A review of the level of care available for mentally ill patients at West Suffolk Hospital, in Bury St Edmunds, was launched following the death of Wayne Webster in 2004.

A PSYCHIATRIC patient who hung himself in his hospital ward might have died because of failings in the health system, an inquest has revealed.

A review of the level of care available for mentally ill patients at West Suffolk Hospital, in Bury St Edmunds, was launched following the death of Wayne Webster in 2004.

In the weeks leading up to his death, the "troubled" 34-year-old, of Bury Road, in Thetford, suffered from such severe depression he was admitted to the hospital under section three of the Mental Health Act.

Mr Webster was readmitted to hospital in December 2004 after slashing his wrists with a knife at his home, but despite two separate pleas from family members who feared he may try and take his own life, staff failed to carry out a full medical assessment of his situation, and he killed himself three days later.


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During the inquest in Bury yesterday, Greater Suffolk coroner Peter Dean said Mr Webster could possibly have been saved if hospital staff had made proper use of the resources available to them at the time.

"The family feel there was a lack of concern felt by hospital staff during the last weekend of his life," he said.

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Reading from statement made by Mr Webster's family, Dr Dean said the former postman had stopped believing anyone cared about him, and thought the world was against him.

Mr Webster was first admitted to West Suffolk Hospital's psychiatric ward in November 2004, after he tried to overdose on painkillers.

Later that month it was decided he needed to be sectioned for his own safety, after once again threatening to take his own life, but the order was lifted three days later after his attitude and behaviour started to show dramatic improvements.

But on December 10, Mr Webster suffered a "catastrophic relapse", and was taken back to West Suffolk Hospital the following morning after he cut his wrists in front of his girlfriend, and jumped through a ground-floor window in his house.

Dr Dean said: "On December 12, Wayne's father and stepmother visited him in hospital. Wayne told them they were selfish for wanting him to stay alive, and he remained underneath the bed cover for the whole of the visit. They went to staff and said they had never seen Wayne so bad, and asked them to keep a close eye on him and make sure he had nothing to harm himself with.

"That night Wayne rang his girlfriend and told her he was going to kill himself. She called the hospital and told staff what Wayne had said to her, and asked them to remove a belt and knife she thought he had, and to keep a close watch on him."

When a staff nurse went in to check on Mr Webster in his room on the hospital's Southgate Ward, at around 1.50am on December 13, she discovered him hanging from his bathroom door with a belt around his neck. He was pronounced dead at 2.30am.

It was later revealed that Mr Webster, who had been known to try and "manipulate the system" in the past, had put clothing underneath his bed sheets to give the impression he was in bed and asleep when nurses made their hourly visits to his room.

During the inquest, hospital staff said Mr Webster had seemed "settled" on the night he died. They recalled the conversation with Mr Webster's girlfriend, but said there had been no mention of a belt or of him killing himself, and the word "harm" had been used instead.

But they admitted no action was taken to greatly increase the level of supervision given to Mr Webster during the night, and an on-call member of psychiatric staff was not notified of his return to hospital, nor asked to undertake a full medical assessment.

"It is not unreasonable to expect people to take every reasonable step, and in these circumstances it might be felt it was reasonable to make a full mental-state assessment, which in this case this was not carried out," said Dr Dean.

"There was no protocol in place to notify a member of psychiatric staff of Wayne's readmission to hospital, and no one was made aware of the concerns raised by the family.”

He added: "There is no suggestion that staff did anything other than act in good faith in assisting Wayne, but there are questions over the level of communication and supervision.

"We have no way of ever knowing what the outcome would have been if a full mental-health assessment had been carried out, but there is the possibility this might have prevented Wayne's death."

Sandra Cowie, the NHS Trust's director of mental health and social care at the Mental Health Partnership, said new measures had been put in place since Mr Webster's death to improve the system.

"It is key that risk assessments are carried out with different members of staff," she said. "There were issues raised around communication, and we have already made some changes and will continue to look at this.

"We have also finished developing a new search policy for when people come onto the wards, and we are making sure we listen to and involve relatives, as well as taking action on what they are saying."

A narrative verdict was recorded, stating: "Wayne Webster took his own life following a return to hospital. A full psychiatric assessment which may have prevented his death, following specific concerns raised by his family, was not conducted."

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