An "enhanced" inquest held by HM Coroner for Derby and South Derbyshire, Dr. Robert Hunter, concluded on 8 June 2009 that a failure to conduct a risk assessment, poor communication and staffing levels gave rise to a set of circumstances contributing to the suicide of Mr. Albert Banks, an 88 year old man who was found hanging from his oxygen tubing in a toilet in Derbyshire Royal Infirmary on 2 April 2008.
Albert Ernest Banks
On the 2nd April 2008 Albert Ernest Banks took his own life. Mr. Banks had been admitted to hospital on the 24th March 2008 with worsening heart failure due to aortic stenosis. Despite escalating medical treatment Mr Banks continued to deteriorate. On the 1st April 2008 he had been in low mood and wanting to die.
On the 2nd April Mr. Banks had intimated to hospital staff and his family that if he was discharged home he would kill himself and he had informed a member of staff he had already made provision at home to do this. Mr. Banks informed a doctor that if he was discharged he would kill himself
On the 2nd April 2008 and that week, due to staff sickness and maternity leave the staffing of the ward by nurses was not optimal and although the levels did not place any patient in danger it reduced the amount of clinical time available for the nursing staff to engage with their patients.
Both written and verbal communication between staff was less than ideal with significant statements and consultations between healthcare professionals and family not being documented. Nursing staff were aware that Mr. Banks was to be seen by a doctor but the nurses were not made aware of the doctor's conclusions.
Concerns by staff and family and Mr. Banks's behaviour and express statement on intent prompted a doctors to see Mr. Banks, however, no objective risk assessment was made and there was an assumption that there was no risk as Mr. Banks was not going home.
These three issues acting collectively did not cause Mr. Banks death however it gave rise to a set of circumstances where they can be regarded as Being contributing factors in the death.