A mental health trust was neglectful in its conduct when a patient died two days after being admitted to hospital, a coroner has said.
Stephen Neville, 68, died on Beech Ward at Rochford Community Hospital which is run by Essex Partnership University NHS Foundation Trust (EPUT).
A prevention of future deaths report was issued to the trust following a nine-day inquest which found a “series of serious failings” contributed to his death.
Paul Scott, chief executive at EPUT, said: “My deepest sympathies remain with Stephen’s family, friends and loved ones and I would like to apologise for the failings in his care.”
Essex area coroner Sean Horstead concluded at the inquest, which took place in October, that Mr Neville’s death was “contributed to by neglect”.
He was found dead at the hospital on 18 December 2021, having taken his own life, after being admitted as an inpatient two days earlier.
In the report, published on Wednesday, the coroner said: “His direct admission had bypassed the trust’s usual referral, gatekeeping and bed management processes, contrary to trust policy.”
An associate specialist psychiatrist undertook a clinical review the day after he was admitted and had been unaware Mr Neville was prescribed daily Lorazepam in the community for about 14 months – alongside antidepressant medication.
Mr Horstead found there were “failures to identify and communicate up-to-date risk assessments” between mental health teams.
He also said staff “failed to engage with family members” to seek information relevant to Mr Neville’s risk.
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The coroner concluded there was “failure to appropriately manage the unlocked shower room” where he died and to “mitigate the clear risks” of his unsupervised access to the room.
He was worried about staff not observing patients well enough and was concerned about the “quality of the conduct of the EPUT staff of such critically important observations” regarding “highly vulnerable inpatients at risk of suicide”.
EPUT said it had invested £20m into their wards to improve safety.
Four neglect findings
BBC East’s health correspondent, Nikki Fox, said EPUT had received at least four neglect findings from inquests this year: Darren Turner, Abbigail Smith, Elise Sebastian and now Stephen Neville.
“These tragic deaths may have happened a number of years ago, but in June 2021, before Mr Neville’s death, Mr Scott said he was committed to doing everything he could to ‘ensure EPUT provides the safest possible care’,” she said.
He was speaking after the trust was fined £1.5m over 11 patient deaths, and for breaching health and safety laws surrounding ligatures in its units.
EPUT is the subject of a public inquiry examining more than 2,000 deaths of mental health patients.
Fox continued: “The number of neglect findings and prevention of future death notices issued by coroners in relation to the trust is not reducing. This has to be of concern to the Lampard Inquiry, which has said it is monitoring inquests.”
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