Robert Oldham, instructed by James Bell of Kingsley Napley LLP, represented the family of a man who very sadly died after he was ‘provided with the opportunity to take his own life’ at a mental health respite centre in Surrey, following a referral from hospital.
The inquest heard from seven witnesses over six days at His Majesty’s Coroner’s Court in Woking, with findings and conclusions provided this week.
The Coroner agreed with the family’s submissions that Article 2 was engaged and went on to find missed opportunities and flawed decision-making in the care provided first by Surrey and Borders Partnership NHS Trust and subsequently by the Retreat crisis facility in Knaphill.
The Coroner found that the deceased should not have been referred to the Retreat, and that the Retreat should not have accepted the referral, given the complex needs of the patient and the risks posed by his mental ill-health. The Coroner concluded that the Retreat ‘was not appropriate to receive’ the deceased, as it did not provide the level of care needed. On the morning that the deceased died, there were missed opportunities to protect and care for him.
Further flaws were found in various aspects of care, including risk assessment methodology, referral mechanisms, and adherence to standard operating procedures.
The inquest returned a narrative conclusion that reflected failings in care and the deceased’s death by suicide.
Further details about the case can be found on the Kingsley Napley website.
