We represent the family of Simon Willson, who died on 23.01.10, at the Kent & Canterbury Hospital, aged just 34, when he took his own life by hanging himself with his own belt, within a disabled toilet, following admission to hospital having taken an overdose.
He left a widow, Melanie, together with their 2 young daughters.
We have just received a Letter of response from the National Health Service Litigation Authority admitting that negligent failings in Simon’s care and treatment caused his death.
Having been a successful tradesman and businessman, Simon became unwell during 2008, suffering with depression, and resorted to drug and alcohol abuse.
He sought assistance from Mental Health Services, based in Canterbury, part of the Kent and Medway Social Care Partnership Trust.
It was alleged on his behalf that the Trust failed to treat him adequately from March 2008 onwards.
The Trust has now admitted, within the Letter of Response that it should have done more both in March 2008 and when Simon was referred, for the second time, by his GP, in October of that year.
He should have been given an urgent appointment, given his presenting symptoms and history. Instead he was left to make his own arrangements for assistance with alcohol recovery.
Ultimately, after a suicide attempt, he was admitted to St Martin’s Hospital in Canterbury, at the end of November 2009, where he remained until January 2010.
Wholesale failings in his treatment there are alleged by his family.
It is admitted that the Trust failed to properly engage with and understand Simon’s presenting picture in that they did not work with him on historic issues when he sought assistance.
It is admitted that the Trust rushed to an ill prepared discharge despite Simon remaining severely unwell and at a high risk of suicide.
A summary discharge form was not completed and the plan upon discharge was inadequate.
So too was a further assessment carried out on 12.01.10, following a further suicide attempt that Simon made, practically immediately upon his discharge from hospital.
There was also an unacceptable failure to refer him for him psychological assistance.
The Mental Health Trust were guilty of failings again, on 17.01.10, when the Crisis Team reduced the frequency of their visits to Simon without conducting a full and adequate risk assessment.
Further, on 21.01.10, the Crisis Team and Community Teams, on a joint visit, performed an inadequate assessment and failed to adequately assess risk. They were wrong to transfer Simon from the Crisis Team to the Community Team.
On the morning of his death, Saturday, 23.01.10, Simon presented in a desperate state, at Canterbury Police Station, to the point where the police sectioned him, under the Mental Health Act, and took him to St Martin’s for an assessment.
He was assessed there and found not to be sectionable under the Mental Health Act.
The following morning, the Community Team failed to follow things up and check on Simon’s welfare.
Further, when Simon took another overdose, in the late afternoon, and contacted the Crisis Team, the Team, whilst arranging an ambulance for Simon, failed to communicate with the A&E Team at the Kent & Canterbury Hospital, (the responsibility of the East Kent Hospitals University NHS Foundation Trust).
From his arrival at A&E, there were a succession of failings.
Upon triaging Simon, the bespoke ‘SAD’ Person’s Scoring section to the admission template was not completed.
Further, there was a failure to complete a Mental Health Risk Identifier form (which was not started until many hours after Simon’s admission and then was not completed).
It is further admitted that the Risk Screening Tool (which has been substantially altered since Simon’s death) was flawed in any event.
There was delay in notifying psychiatric services of the need for Simon to be assessed.
Simon was not adequately monitored in ECC.
The record keeping was substandard.
Liaison between psychiatric services and the emergency services/A&E was poor.
Simon was not seen at any point by an A&E doctor during his time in ECC.
Rather, after 4 hours, he was transferred to the CDU, not having been seen by a doctor.
It was admitted that moving Simon simply to avoid a breach of the Government’s 4 hour target (for patients to be seen in A&E) was negligent.
The handover between ECC and CDU was inadequate.
Simon should have been placed in a close observation bed.
Observations of Simon were unacceptable.
He should not have been left alone for more than a few moments when he went into the toilet.
Incredibly, when a nurse checked the toilet door, finding it locked, they failed to call out to check on Simon.
In consequence, whilst in the disabled toilet, on CDU, Simon managed to take his own life, using the belt that he had been allowed to retain.
It is admitted that, but for the negligence on the part of the Trust, Simon would not have died.
Nick Fairweather, who has conduct of this case on behalf of the family, and represented them at the Inquest last year, commented:-
“ It is both remarkable and deeply upsetting that such a sequence of repeated errors could have taken place, with Simon’s care, on the evening that he died.
It is very important that those working within A&E have proper training and liaise thoroughly and effectively with their colleagues from Mental Health Services.
There was a complete breakdown in communication between the two services in Simon’s case.
But for this, he would be alive and with his family today.
Our expert evidence strongly suggests that, with proper treatment, and intervention, Simon would have made a full recovery.
The A&E department at the Kent & Canterbury Hospital has made substantial changes, the family feel, in response to Simon’s case and it is the family’s hope and wish that these lessons learned are long lasting so that another family does not have to suffer in the same way as they have in the future.
Simon’s widow, Melanie Willson, commented:-
“Simon was badly let down by the whole system: historically by mental health services and on the evening he died, by A&E.
He so desperately wanted to get better and was looking for help but simply did not get it.
He would still be with us today if he had been shown the care and compassion you would expect and had people done their jobs properly.
The girls and I miss and think about him every day and always will.”
This case was featured on BBC South East on 03.04.2014. To view the video please see below: