Failures in care contributed to the death of Steven Edwards, a high risk detained patient

The jury at the inquest, touching upon the death of Steven David Edwards, held at Liverpool Coroners Court between 5-14 March 2018, concluded that multiple failures in his care contributed to his death as a result of an unsurvivable brain injury following suspension from a ligature.

Background:

Steven was a well-respected family man, a union representative and a much-loved father. In 2012 he became unwell and began experiencing paranoid delusions. Between 2012 and 2016, Steven was under the care of Mersey Care NHS Foundation Trust. He spent time in hospital and in the community with some periods of remission; however, his paranoid delusions remained.

Following an incident in August 2016 in which Steven refused to return home from a trip to the beach, and later disclosed he had intentions to take his own life, Steven was admitted to Hospital under Section 3 of the Mental Health Act.

He was initially admitted to Broad Oak Hospital, despite his wishes to go straight to Clock View Hospital which was closer to his home and where his medical team were based. The doctor who admitted Steven to hospital recommended he be placed on observations in which he would always be in the line of sight of hospital staff. The inquest heard evidence that this did not happen due to a lack of staff.

Steven remained in Broad Oak for eight days, despite believing he would be transferred to Clock View much sooner. He was eventually transferred following his family raising concerns as to his care.

Once in Clock View, the inquest heard evidence that Steven was not properly risk assessed. The Doctor in charge of his care and his named nurse told the inquest they did not recall acknowledging the fact that his community team had stated, in risk documentation under the heading “Shared Summary of Potential for Suicide and Self Harm”, that Steven was a highly intelligent man who often masked his symptoms, and was at high risk of suicide. Steven was ultimately placed on hourly observations, the lowest level possible, despite his Doctor recommending he be actively engaged with and observed at least every 15 minutes.

Despite his suicide risks and persecutory hallucinations, Steven was placed in a room which was out of sight of the rest of the ward. It was next to the reception which meant the noise he could hear added to his delusional belief that people were talking about him. The door of his room had not been risk assessed as a ligature point.

On 27 August 2016, Steven was approached by the nurse in charge of Alt Ward. She spoke briefly to him and he then went out to the garden with a health care assistant. Just before 7pm, the nursing assistant left Steven in the garden. At some point before 7pm, the inquest heard evidence that another service user approached the nurse in charge of the ward and told her that Steven had told him he would not be here tomorrow, and that he was concerned Steven was going to “do something”.  When giving evidence the nurse in charge stated she could not recall this being said. Two other nurses recalled this being said to the nurse in charge.

Steven’s partner then received a phone call from him, in which he was agitated and distressed. His partner was so concerned about him she immediately telephoned Alt Ward to inform them of her concerns. The nurse in charge reassured her partner that they were aware he was distressed and had offered him medication. This nurse told the inquest she did not feel immediately concerned about Steven following this call.

Despite these two warnings, the nurse did not immediately go to check on Steven, but instead organised leave for other service users, went to the kitchen and eventually to see the service user in the room beside Steven’s.

When attending to the other service user at about 7.10-7.15pm, the nurse noticed something above Steven’s door by chance. She gave evidence that she went to find another member of staff to assist as her personal alarm did not work. When she and another member of staff arrived, they managed to open the door and found Steven who had hung himself by a belt behind his door. An ambulance was eventually called at 7.23pm and Steven was taken to Aintree Hospital, where he sadly died in the early hours of 28 August 2016.

Jury Conclusions:

The inquest jury concluded that the following factors contributed to Steven’s death:

1. Steven was sectioned as high risk. There was a failure to consider all relevant documentation including historical risk factors and information which was not carried through to current risk assessments;
2. There was an inappropriate appreciation of Steven’s risk both individually and environmentally; and
3. There were persistent failures in communication between nursing teams and medical teams.

Steven’s family said:

“We feel badly let down by Mersey Care. We believed Steven would be safe in their care, being properly risk assessed, managed and observed. He was left on his own in a totally inappropriate room. We cared for Steven for four-and-a-half years, with almost no sustained support from Mersey Care, and kept him safe. 15 days in their ‘care’ he was dead. Despite us warning the ward that we had concerns for Steven immediately before his death, no appropriate action was taken to support him or prevent him taking the action he did. The inquest was devastating for us. To hear that information which might have saved his life was not read, not understood or ignored, was heartbreaking. We desperately hope that the concerns raised in Steven’s case are taken seriously this time, so that no other families have to go through what we have suffered.”

Alice Stevens, the family’s solicitor said:

“Steven’s death is yet another tragic and unnecessary death of someone with serious mental illness.  The jury have made damning criticisms of Mersey Care, as previous juries have done, and it is hoped that these will be fully considered and acted upon by this Trust.  Steven’s family have conducted themselves with great dignity through a difficult inquest process. The Coroner quite rightly raised concerns about the time it is taking for changes to be implemented by Mersey Care as a result of Steven’s death. It is hoped that these will be taken seriously and put in to place as a matter of urgency to prevent any further deaths.”

This case has been reported in the Liverpool Echo.

Tom Stoate is a member of Garden Court Chambers' Civil Liberties and Human Rights Team.