Mental health neglect contributed to patient escape death – jury

A jury has concluded that negligence contributed to the death of a man who escaped from a psychiatric hospital despite being known to be a high flight risk.

Jamie Law, 20, escaped while visiting family and was detained for two days at Fulbourn Hospital near Cambridge, where he died in 2021.

The jury found there was “insufficient staffing and an inadequate risk assessment to enable a safe visit”.

The NHS trust involved said changes had since been made to the inpatient unit.

Mr Rowe's mother, Wendy Setterfield, told an inquest at Peterborough Town Hall that her son was “accepting, non-judgmental and never had a bad word to say about anyone.” ” he said.

Mr Lowe was seen by the mental health team at Nottingham's Accident and Emergency Department, where he was a student, on November 13, 2016, as he was showing signs of psychosis.

Jurors said his flatmates had called for help, claiming he had self-harmed after “behaving strangely the previous night”.

He was taken to Mulberry Ward 2 at Fulbourn Hospital, close to his home in the Peterborough area.

The jury found: “He had been identified by multiple clinicians as a high flight risk and was admitted to a ward with an airlock system to reduce that risk.”

But jurors said the mother's visit took place in a family room in an airlock, “meaning that security systems were compromised and the location was inappropriate”.

The jury found that “inadequate staffing levels meant that staff did not have time to read all of the patient's records and understand the full extent of Jamie's risk of disappearance.”

On the day the mother met, jurors were told the ward was understaffed and the nurse in charge said: “If I had known the full story, it would not have been safe for the mother to be in the family room in the airlock.'' It should have been.”

The inquest heard Mr Lowe fled when staff opened the door on November 15 and was hit by a truck later that day.

Coroner Philip Barlow said: “We agree that there was no suggestion that Jamie intended to take his own life.”

Jurors said the findings were “evidence of neglect that directly contributed to Jamie's death”.

Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) said in a statement: “Jamie Roe’s death is a tragedy and we continue to offer our deepest condolences to his family and friends.

“We fully accept the jury's findings and the coroner's recommendations.

“Patient safety is our top priority and we have implemented a number of changes and improvements across our inpatient units.”

These include enhanced patient risk training for all inpatient nursing staff, up-to-date training and documentation of patient observation levels, and relatives are now meeting patients within the ward.

Additionally, although family rooms were only used for visits involving children under 16 and had been reverted to pre-COVID-19 use, there has been no formal, documented evaluation of family room use. Visits were to be supervised as necessary.

In a statement, Mr Law's family described him as a gentle man with a “kind personality” and said they would forever cherish “many happy memories”.

They continued: “Jamie was extremely unwell at the time of his death and the wider circumstances surrounding his death will always be of great distress to our family.

“However, we are grateful for the generosity of the CPFT in admitting that a failure was made and hope that lasting lessons can be learned from Jamie’s death.

“While our family would like to emphasize that we do not blame anyone for what happened to Jamie while in the care of the CPFT, we do wish to emphasize that he feels he has been let down by the entire system. Masu.”

If you are affected by any of the issues raised in this article, you can contact Samaritans by calling 0330 094 5717. Support is also available. BBC action line.