The inquest into the death of Peter Barnes at Cygnet Hospital in Wyke concluded on 6 November 2013, with a jury finding that Peter took his own life while the balance of his mind was disturbed, contributed to by neglect and inadequate systems.
HM Assistant Coroner for West Yorkshire (Western District), Neil Cameron, also indicated he would be writing to Cygnet Hospital under paragraph 7 schedule 5 of the Coroners and Justice Act 2009 (which has replaced the function of Rule 43 of the Coroners Rules 1988) to express concern at the systems of communication of important information about patients at the hospital.
Peter suffered from hebephrenic schizophrenia and had been admitted to the psychiatric intensive care ward at Cygnet Hospital, a private company, under section 3 of the Mental Health Act 1986 on 9 September 2011.
The jury heard evidence from Peter's mother, Karen Barnes, and from nursing and medical staff, that Peter would often express suicidal ideation during his time there - which was not always noted in his medical records.
On 1 October 2011, Peter was overheard on the telephone saying he planned to take his own life using his shoelaces, and later that day was seen with red marks around his neck - which, a number of doctors and nurses told the inquest, were suggestive of a suicide attempt having been made by Peter.
This information was not, however, brought to the attention of Dr Keith Rix, Peter's consultant psychiatrist, who subsequently granted him unescorted ground leave on 3 and 12 October 2011. Dr Rix told the inquest that no qualified clinician could have thought that information about Peter's apparent suicide attempt did not need to be brought to his attention and that, had he known about it, he would not have granted Peter unescorted leave.
Neglect and inadequate systems
On 13 October 2011 Peter failed to return from a period of unescorted leave in the hospital grounds. Cygnet staff commenced a search which the jury found to be "untimely and inappropriate", lasting only 10-15 minutes and failing to cover large areas of the grounds.
The jury also found that the information passed on to West Yorkshire Police by Cygnet was "inappropriate" - including one senior nurse telling police that "I think he will be sat somewhere with a couple of cans of Stella" when asked by the police if there were any "genuine concerns" for Peter.
Peter's body was not found until a week later on 20 October 2011, suspended by his shoelaces from a tree only yards from the hospital, following a police search lasting only 10 minutes.
After over three weeks of evidence, the inquest jury found that Cygnet Hospital's systems and methods of communication for ensuring his responsible clinician had all the information needed to decide whether or not to allow unescorted ground leave had been "inadequate", and had led to "an error which gave him the opportunity to take his own life". They also found that Peter's death was contributed to by neglect in the form of "gross failures of hospital systems and the failure to communicate and identify significant events".
Various failures by West Yorkshire Police properly to instigate their missing persons procedure in Peter's case had previously been identified by the Independent Police Complaints Commission (IPCC) as "falling well below the expected standard", and the Coroner indicated he would also have made a report under paragraph 7 schedule 5 expressing concerns about the police search but for changes already implemented by West Yorkshire Police to improve management of missing persons investigations following Peter's death.
Peter's mother Karen Barnes said after the inquest:
"The jury's determination is what we knew all along: Peter was failed by Cygnet. We would not have got the justice Peter deserved without INQUEST and our legal team. We now hope what happened to Peter and the outcome of the inquest will be used as a precedent and lesson to be learned stopping any other families going through the agony we have suffered."
Tom Stoate represented the bereaved family. He was instructed by Chris Topping of Broudie Jackson & Canter Solicitors and supported by INQUEST.