Inquest finds that a lack of communication between mental health teams, particularly after Ashley’s most recent admission, had partly contributed to his death.
The jury found that the process of discharging him from the Rochdale hospital had been ‘wholly insufficient’ and that there had been a lack of documentation relating to his condition for medics to use.
They also concluded that the ‘communication and handover documentation was fundamentally flawed’, and that this needed to be improved.
A jury has found mental services were ‘fundamentally flawed’ in their handling of a beloved son and brother who killed himself in a hospital ward.
Ashworth had been admitted to hospital and underwent months of treatment after he jumped from the Arndale Shopping Centre car park and survived, an inquest at Rochdale Coroners Court has heard.
The 34-year-old spent eight years battling his ‘plummeting’ mental health – which came on ‘without any signs’ while in his mid-20s, his family said.
Ashley was diagnosed with paranoid schizophrenia.
Ashley was admitted to Stepping Hill before being transferred to Birch Hill and placed on a psychiatric intensive care unit on January 8, 2018.
He was released on February 1 – in a move that ‘surprised’ his family.
“They need the bed, can you pick me up,” Ashley texted his dad, heard the court.
The family say they never heard from the hospital about his discharge.
After spending a few weeks with his parents and brother, on February 18, 2018, Ashley was rushed to hospital with ‘catastrophic injuries’ after ‘jumping from the Arndale shopping centre car park.
He was found with serious wounds but miraculously survived and, after multiple operations, was beginning to regain his physical health.
However, while he was being treated at Salford Royal Hospital, he made an attempt at hanging himself, the inquest heard.
Later, he was moved to a psychiatric unit at Fairfield Hospital but sadly on February 10, 2019 – less than a year after falling from the car park – he was found dead in his room.
Ashley’s medical cause of death was found to be hanging, according to the pathologist that conducted a post mortem examination.
Ashley’s family has criticised the mental health care their loved one received, saying that health care teams were ‘reactive instead of proactive’ and had a habit of ‘only intervening at the point they have to’
Brother Christopher also raised concerns that Ashley’s care ‘was too clinical’, adding that he felt medics ‘did not take the time to get to know’ their patient.
Nicola Kidd, manager of the North Ward at Fairfield General, refuted the claim. She said that staff at the unit in Fairfield attempted to get to know Ashley by ‘engaging with his musical interests’, watching videos of him playing guitar which he had uploaded to YouTube.
Trying to develop a relationship with Ashley was difficult, however, as he remained detached from other people due to his mental health condition, said the manager.
But, following jury deliberations, the inquest found that a lack of communication between mental health teams, particularly after Ashley’s most recent admission to Birch Hill, had partly contributed to his death.
The jury found that the process of discharging him from the Rochdale hospital had been ‘wholly insufficient’ and that there had been a lack of documentation relating to his condition for medics to use.
They also concluded that the ‘communication and handover documentation was fundamentally flawed’, and that this needed to be improved.
After hearing the evidence, the jury concluded that Ashley’s death was the result of suicide.
Coroner Lisa Judge said that she would likely have issued recommendations for change within the mental health services that cared for the young artist, but staff within the hospital had already undertaken a review and made changes.
“What is apparent is that, as a result of the root cause investigation, a formal document was prepared with recommendations that the authors had and all of those recommendations have been taken forward by the trust,” the coroner said.
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Source: Manchester Evening News, 11th March 2021
CHARM 