Neglect at Southend Hospital led to man’s death – coroner

Action must be taken at a hospital where a suicidal man died, a coroner warned.

Aaron Deeley, 43, died in January 2022 after falling from a proven defective window on the second floor of Southend University Hospital.

Mr Deeley had been proven to have attempted suicide several times and was supposed to be under personal observation. However, this was withdrawn from him a few hours before his death.

The Mid and South Essex NHS Foundation Trust (MSE) acknowledged deficiencies in its care during an investigation in May and said action had been taken.

In a report aimed at preventing future deaths, Essex Coroner Sonia Hayes said there had been “failures in care and safeguarding” by the trust which contributed to Mr Deeley taking his own life.

Mr Deeley was admitted to Southend’s acute inpatient unit awaiting assessment by the Essex Partnership University Trust (EPUT) Mental Health Liaison Team.

A jury concluded in May that there were several problems in the care of Mr Deeley.

It found that there had been discrepancies in the completion of the extended observation form for the hospital the day before his death.

In addition, his discharge letter from Southend Hospital following a previous suicide attempt in December 2021 did not contain sufficient details.

The psychiatric team’s discharge documents were sent to the wrong address of the GP.

The Coroner stressed that there had been a lack of clarity within the Medical Council as to what conditions must be met to ensure that a patient awaiting an examination under the Mental Health Act can be subjected to one-to-one observation.

She said the Mid and South Essex Trust’s policy on the matter was “confusing”.

Ms Hayes said: “There is a gap for patients awaiting an assessment under the Mental Health Act who also require physical healthcare where a significant risk has been identified, requiring a patient to be taken into custody for their own safety.”

Matthew Hopkins, chief executive of Mid and South Essex NHS Foundation Trust, said a full investigation had taken place following Mr Deeley’s death.

He said: “We have enhanced our policies and procedures to ensure safe care for mental health patients on our wards. Immediate action has been taken to secure windows and appropriate measures have been put in place to ensure our windows are safe for all patients.”

Paul Scott, CEO of EPUT, said the trust would look at the coroner’s recommendations and was “responsible for ensuring patients receive the right care at the right time”.

He said the trust’s mental health liaison teams worked closely together to ensure patients “receive the mental health support most appropriate to their individual needs”.