Today, at an inquest into the death of a 54-year-old father of one, Peter Docherty, from Southall in West London, the coroner found opportunities were missed to minimise the risk Mr Docherty posed to himself.
Mr Docherty was found dead at Ealing Broadway Station on 7 January 2015. He had been suffering from severe and enduring mental illness for many years but had been managing his condition well. After moving from supported care to independent living however, he began to struggle and became distressed at the feared closure of the Solace Centre, an out-of-hours support facility.
In the days prior to his death he was under the care of the Ravenscourt Ward, part of an NHS mental health unit in Hammersmith, West London, after reporting he was hearing voices and was considering jumping in front of a train.
The coroner, Ms Ormonde-Walshe of West London Coroner’s Court in Fulham, in a narrative conclusion found a number of serious failings by the Ravenscourt Ward which may have contributed to Mr Docherty’s death.
Mr Docherty had been diagnosed with schizoaffective disorder and was taking medication to control his illness whilst living in supported accommodation. He had a good relationship with his mental health care coordinator and regularly attended the Solace Centre, an out of hours mental health resource centre.
In November 2014, Mr Docherty moved to his own independent flat in Southall. He was also informed of the imminent closure of the Solace Centre. Struggling to manage with the practical tasks required by his new living arrangements and distressed by the planned closure of the Solace Centre, Mr Docherty’s mental health deteriorated and at 7.10pm on 4 January 2015, he presented to the Urgent Care Centre at Ealing Hospital, reporting he was hearing voices and was considering jumping in front of a train. At 1am on 5 January 2015 he was transferred to Ravenscourt Ward.
Mr Docherty was assessed as a high-risk patient and admitted. On the morning of 6 January 2015, he said he was feeling better and was granted leave from the ward. He phoned his consultant to say he did not wish to return. His consultant returned his call but was unable to reach him so left a message. Mr Docherty did not respond so was deemed to be on leave that evening. He returned briefly to the ward in the evening but again stated he was feeling fine so it was agreed he would return for a review with the consultant in the morning.
He did not return the following day and was found dead at approximately 9.10am on 7 January 2015 having been struck by a train at Ealing Broadway Station.
The coroner was critical of the fact that there had been no contact with Mr Docherty’s family or friends on his admission to hospital, during his stay or when the decision to allow him to leave was taken. In addition, no risk assessment was undertaken prior to the decision to allow him to go home overnight, despite the fact that when he was admitted to hospital, he did not feel safe at home.
She was also critical of the fact that staff on the ward had failed to notice that he had not returned when he was supposed to, describing the attitude to patient leave as “relaxed”. He was allowed to leave quite soon, within 48 hours of admission and she felt that not contacting his family was surprising and represented a missed opportunity to provide protective factors. She said that involving the family should be more than just a paper exercise.
In addition, Mr Docherty’s treating psychiatrist had reservations about allowing him to stay at home overnight, but these were not documented or handed over to the other team members. Record keeping and documentation was noted to be poor. Had better notes been made this have resulted in a different outcome.
Ms Ormonde-Walsh was also surprised by the nurses’ attitude to medication. She found it worrying that Mr Docherty’s medication was not given on several occasions during his stay, and that it was not checked with him that he was taking his medication when not on the ward.
The Court heard that in the two years since Mr Docherty’s death, numerous changes have been made, including ensuring that each patient now has a named nurse, and that patients who are on leave from the ward are now more closely monitored.
Agata Usewicz, medical negligence lawyer at Hodge Jones & Allen is representing Mr Docherty’s family. She says: “Until a few months before his death Mr Docherty had been managing well. He was involved with his community, had a good relationship with his son and felt ready to live independently. He had good insight into his condition therefore when he became suicidal in January 2015 he went looking for help. He was admitted to hospital as a high-risk patient but within 48 hours was deemed safe to leave. The coroner’s findings make it clear that the hospital missed opportunities to protect Mr Docherty. I hope that lessons have been learned from this case and that the changes that the Trust has made will mean that vulnerable patients in the care of Ravenscourt Ward care are better protected in future.”
Marc Docherty, Peter’s son said: “My dad was a lover of people with a kind and generous spirit. He was a fantastic father and a loving husband who will be sorely missed by all his family. The inquest process has been a hugely difficult experience for us, particularly given this week is the anniversary of my father’s death. It has been hard to hear about the errors made by NHS staff and to acknowledge that, had there been proper therapeutic engagement then he might still be here today.”
The inquest concluded that Mr Docherty carried out an act of self-harm while suffering from mental illness.
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Notes for Editors
Hodge Jones and Allen
- Hodge Jones and Allen is one of the UK’s most progressive law firms, renowned for doing things differently and fighting injustice. Its managing partner is Patrick Allen.
- For almost 40 years’ the firm has been at the centre of many of the UK’s landmark legal cases that have changed the lives and rights of many people.
- The firm’s team of specialists have been operating across: Personal Injury, Medical Negligence, Industrial Disease, Civil Liberties, Criminal Defence, Court of Protection, Dispute Resolution, Employment, Family Law, Military Claims, Serious Fraud, Social Housing, Wills & Probate and Property Disputes.
- In 2016 the firm launched Hearing their voices – a campaign to raise awareness and build conversations around the issues and the injustices we might all face.