Peter Franklin, aged 67, died on 19th August 2013, when he took his own life by jumping from a motorway bridge on the M20, close to Maidstone Hospital.
He did so in a state of despair, having tried to access help at the hospital no fewer than 5 times that day. He had also been unsuccessful in getting help from mental health services.
Peter had a long standing history of anxiety and depression as well as suicide bids.
He first presented to Maidstone Hospital’s A&E Department at just before 5am on the morning of 19th August. He presented there again at 7:30am, 1:49pm, 4:14pm and 8:30pm. In between times he presented at the mental health facility at Priority House in Maidstone at 10am and 4pm.
Peter was in a highly distressed condition, presenting bizarrely in A&E and it was clear, and recorded, that he was highly anxious and suicidal.
Mental health services would only give him a future appointment and refused to attend the hospital to assess Peter during his 4th attendance there.
Following this, the A&E department ordered Peter a taxi to take him home.
Shortly afterwards, the taxi driver returned Peter, for the 5th and final time, informing the A&E staff that Peter had got out of the taxi at the bridge on the motorway and run to jump from it. He had to be stopped by the taxi driver and persuaded to return to the hospital.
Despite the taxi driver explaining all this and expressing his concerns Peter was discharged once again.
Shortly afterwards he took his own life.
An inquest into his death was held at the end of April 2014 at the end of which the Coroner made a Regulation 28 Report to Prevent Future Deaths.
She also referred the psychiatric nurse who was on duty for the crisis team on the day of Peter’s death to the Nursing and Midwifery Council.
She was subsequently found guilty of professional misconduct by the Council and given a 2 year conditions of practice order which included “writing a reflective piece”. The Nursing and Midwifery Council also roundly criticised the Mental Health Trust.
By way of a Letter of Claim dated 20th July 2016, sent on behalf of Peter’s Widow, Lynne, we alleged negligence and breach of the right to life against both Trusts, citing individual and joint failings.
By a Letter of Response, eventually received on 29th March 2017, solicitors for the Maidstone and Tunbridge Wells NHS Foundation Trust (responsible for Maidstone Hospital) and Kent and Medway NHS and Social Care Partnership Trust (responsible for mental health services) made wholesale admissions as to the failings alleged including that:-
It was a breach of duty for Maidstone Hospital to discharge Peter home at 7:30am on the day of his death.
That both Trusts were negligent to discharge him from A&E without a mental health assessment when he attended at 4:14pm.
That, in relation to his final attendance, the Maidstone Trust should have fully reassessed him and the Mental Health Trust should have arranged an urgent reassessment of his mental state and risk of suicide, following his being returned to Maidstone Hospital by the taxi driver.
It was further admitted that, but for these failings, Peter would not, on the balance of probabilities, have taken his own life.
Subsequently, the case has been settled, on behalf of Lynne, without the need for legal proceedings.
Nick Fairweather, who had conduct of this matter, commented:-
“To properly appreciate and learn lessons from what happened in Peter Franklin’s case we have to imagine someone with a serious life threatening physical illness in severe distress presenting at A&E and being repeatedly turned away. Such a situation would cause outrage and until we have the same response to mental health patients being effectively refused treatment we will not move forward towards the parity of treatment that is much lauded currently whilst little tangible is being done to achieve it.”
Peter’s Widow, Lynne, commented:-
“I am pleased that this litigation is over but determined to ensure that both Trusts learn lessons from their mistakes which took Peter from us. Too often mental health services are the poor relation to physical healthcare provision and the failure to properly support people who present in A&E is a very serious problem. So too the tendency of doctors to dish out pills rather than getting to a proper underlying diagnosis and treating people suffering with mental health problems through therapies and the like. I intend to campaign now in Peter’s name and memory to improve mental health provision.”