On 30 March 2011 at the culmination of a two week inquest into the death of 24 year old Mark James Dakin, a patient detained under the Mental Health Act in a Psychiatric Intensive Care Unit (PICU) in Bolton, a jury sitting at Bolton Coroners Court returned a damning narrative verdict and found that Mark's death was contributed to by the hospital's neglect.
Mark suffered from a mental illness and at the time of his death was detained under section 2 of the Mental Health Act 1983 in Maple House PICU. Mark was known to be at risk of suicide in the community and had tried to escape from Maple House on three occasions (by attempting to scale the fence). Mark successfully escaped on two occasions, the second time being just six days before his death. On one occasion Mark had gone to the top of a multi-story car park and thought about jumping off. Mark eventually died on 17 January 2008 after jumping from a high roof top. Greater Manchester West Mental Health NHS Foundation Trust, who ran the PICU, knew the fence was not secure as prior to Mark's death as there had been six successful absconsions by patients. Nine days before Mark's death a decision to increase the height of the fence was agreed by the Trust, but due to a lack of monitoring of Mark he managed to escape. The inquest also explored the adequacy of Mark's care plan and risk assessments.
The jury found that Mark Dakin took his own life whilst the balance of his mind was disturbed and that this was contributed to by neglect. They jury recorded in their narrative verdict that:
At the time of his death Mark was a detained patient and on the 17th January 2008 there was probably a risk that mark would abscond from Maple House which was not appreciated. This was probably in part because the Care Plan, Risk Assessment and Risk Management Plan were not updated and did not include a classification of risk. On 17 January 2008 there was probably a risk that Mark would take his own life if he absconded form Maple House and members of staff were aware of this risk. Members of staff did not take appropriate precautions to prevent Mark from taking his own life. It would have been an appropriate precaution to have: included in Mark's Care Plan or Risk Management Plan an instruction to staff to keep a more intensive watch upon him including a watch on the courtyard door when he was in or near the courtyard, to have locked the courtyard door immediately after Mark returned to the ward from courtyard on the morning of 17 January 2008 and ensured that there were not chairs near to the courtyard door on the morning of the 17 January 2008. There was an appropriate system in place for ensuring staff were aware of the Trust's AWOL policy.
HM Coroner Mrs. Jennifer Leeming is intending to make two rule 43 recommendations to the Care Quality Commission regarding the height of fences in similar facilities across the mental health estate and the need for Health Care Assistants to be trained in care planning and related matters.
Sharon and Paul Dakin, Mark's parents, said:
After hearing harrowing evidence, the jury have found Mark's death was contributed to by the hospital's neglect and that staff failed to take adequate precautions to protect Mark and prevent him from absconding from Maple House. We are pleased the trust's failings have been recognised and that the coroner has made recommendations to ensure Mark's death was not in vain.
Deborah Coles, Co-Director of INQUEST, said:
It is crucial that there is proper monitoring of the implementation of the coroner's rule 43 recommendations in order that the national significance of this important inquest is acknowledged and acted upon, so that further deaths are prevented.
INQUEST fears that there are other preventable deaths of detained patients that do not receive this same important level of public scrutiny.
Fiona Borrill, the family's solicitor, said:
In July 2010 the National Confidential Inquiry into Suicide and Homicide by People with mental illness revealed that between 1997 and 2007 there were 1128 patient (psychiatric) suicides of people under 25. The figures suggest that many of these deaths are not being properly investigated and lessons learnt. This needs to be urgently addressed.
The parents of Mark Dakin were represented by INQUEST Lawyers Group members counsel Kirsten Heaven of Garden Court Chambers, instructed by Fiona Borrill of Lester Morrill Solicitors.