Inquest jury finds death of 72 year old man on psychiatric ward contributed to by neglect and systemic failures

Thursday 8 December 2022

Stephen Clark of Garden Court Chambers acted as counsel for Larry's family, instructed by Aimee Brackfield of Simpson Millar.

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The jury at an inquest into the death of 72-year-old Larry Spriggs who fell out of a 2nd-storey window at Farnham Road Hospital has recorded a conclusion of death by misadventure, including a finding that Larry’s death was contributed to by neglect of the NHS Trust (Surrey and Borders Partnership NHS Trust).

Mr Spriggs from Camberley, Surrey, had been admitted as a voluntary patient on Victoria Ward – an inpatient mental health ward at Farnham Road Hospital, Guildford – on 25 May 2021, over concerns for his safety.

His body was found in the hospital grounds by a takeaway delivery driver on 27 May 2021.

At an inquest which concluded yesterday at Surrey Coroner’s Court, the jury and the coroner heard that Larry had agreed to be admitted after he started to experience hallucinations, but that he had become distressed and anxious by being isolated in his room as a result of Covid-19 restrictions.

Evidence was also heard that despite concerns over his behaviour, he had been taken off 1:1 observations. Instead, the observations moved to intermittent observations, which were meant to be 5-6 checks every hour at unpredictable, irregular intervals. An emergency agency Healthcare Assistant (HCA) was responsible for the checks on the night of his death.

After 10pm, the HCA went to check on Larry and eventually noticed that Larry was missing from his room, but instead of raising the alarm, he decided to search the ward, despite not knowing what Larry looked like.  

The jury heard that Larry’s body was lying on the floor under the window of his room for 30 minutes before a delivery driver for Deliveroo happened to drive past and call 999, and that he had exited the window feet first.

Throughout the inquest, concerns were raised about the lack of leadership and management on the ward, and further evidence was heard about poor record keeping, poor risk assessments, a lack of integrity/security of the building, and a lack of knowledge about how to carry out observations of patients.

Larry’s partner of 36 years, Nicolyn Moore, was supported at the hearing by Aimee Brackfield, a public law expert at Simpson Millar, and the charity INQUEST.

Speaking following the inquest, Aimee from Simpson Millar said: “Throughout the inquest, we have heard of multiple, significant failings in the care that Larry received, and the suitability of the hospital to manage the needs of people with complex mental health needs."

"In addition to poor management and leadership on the ward, we also heard evidence that junior staff (HCAs) did not have the adequate knowledge required to perform very basic, yet potentially lifesaving tasks such as observations of patients.

The jury’s conclusion of death contributed to by neglect is reflective of the seriousness of those failings, and Larry’s partner, Nicky, is understandably distraught to have learnt that more could and should have been done to prevent him from harm."

“Immediate action is now needed to bring about significant improvements in the running of, and the security measures in place at the hospital to protect both current and future patients.”

In the Record of Inquest (ROI) it was noted that inadequate observations and inadequate training for staff on the evening of 27th May 2021 ‘made a material contribution to Mr Spriggs death’.

The ROI went on to say that the death was ‘caused or more than minimally contributed to by the failure on the part of Surrey and Borders Partnership NHS Foundation Trust to ensure the adequate implementation of intermittent observations in relation to Mr Spriggs’s care’.

Larry’s partner, Nicolyn (Nicky) Moore, added: “Larry was a wonderful life partner, an amazing father and grandfather, and a true and loyal friend.

"Mine and his children’s whole lives have been irrevocably changed by what happened. It took enormous strength for Larry to hospital to seek help. It was not in his nature, as he always wanted to support others before looking after himself. I truly and deeply wish Larry had never gone to hospital. I believe that he would still be here today if he hadn’t."

Nicky added that while the death of a loved one is something you can never come to terms with, to have lost her partner of almost 40 years under such horrific circumstances has been ‘almost too much to bear’.

She said: “There are no words to describe how it feels to have lost Larry. His death has left a hole in my life that can never, ever be filled. I miss him dearly.

"However, what has been particularly difficult to hear is the mounting evidence to suggest that more could have been done to help him when he was desperately in need. If only staff had done what they were supposed to do, including simply talking to Larry to engage with him and to distract him, his death could have been avoided.

“While we have known for some time that there were failings in the care that he received, the full extent of the evidence that has come to light throughout the inquest has been truly shocking. More distressing was hearing the inconsistencies and discrepancies in accounts of the witnesses who last saw Larry."

“While it is too late for us, I hope that following today’s conclusion that lessons are learnt, and that no other family should have to endure the pain and heartache that I have carried for the last year in the future.”

The content above has been reproduced from a Simpson Millar press release.

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