Senior Coroner to make report to the Department of Health and Greater Manchester Health & Social Care Partnership to prevent future deaths.
At the time of Martin’s death, there was a failure to conduct a detailed risk assessment in the period while a bed was sought or to agree a joint plan to manage the risk.
It is probable that failure contributed to his death.
Martin Gibbons, 52, from Ashton-On-Mersey, Sale, was found dead at Stamford Golf Course in Stalybridge in March last year after he had absconded from hospital whilst awaiting medical treatment.
On the morning of March 19, 2020, Mr Gibbons had been admitted to Tameside General Hospital following an incident while staying at his younger sister’s home in Glossop.
Mr Gibbons’ sister, Terri Blair, had awoken in the morning to a series of ‘alarming’ text messages implying he was going to hurt himself.
Mr Gibbons was found outside in a nearby street with a large number of cuts to his arm and a half-empty bottle of whiskey.
He was admitted to Tameside General Hospital where his cuts were seen by doctors and then moved to a designated mental health room for further assessment.
When admitted to hospital on the morning of March 19, Mr Gibbons, who was reported to be in a ‘delirious and drunk’ state, told doctors he had been receiving threats but would not elaborate further.
He told staff that the incident earlier in the morning had been a ‘spur of the moment’ action.
Following an assessment by the mental health team from Pennine Care NHS Foundation Trust, who work alongside Tameside General, Mr Gibbons was deemed to be a ‘moderate to high’ risk to himself and others.
Mr Gibbons was then given a choice to either stay in hospital voluntarily for psychiatric care or be sectioned under the Mental Health Act. He cooperated with staff and agreed to stay in hospital.
As a Trafford resident, however, he was unable to stay at Tameside and a request was made for an out-of-area bed at a hospital closer to his home.
He and his family were informed that there could be a long wait due to bed shortages but the inquest heard that no procedures were ‘visibly’ put in place to keep an eye on Mr Gibbons while he waited for a bed to become available.
Senior Coroner Ms Mutch also questioned a lack of documented risk assessment for his care.
Ms Mutch told the court: “There was no evidence that a risk assessment was documented in relation to Mr Gibbons and the risks that he presented in the period between the assessment being completed and the bed being identified.
“It’s clear on the evidence that it was impossible for anyone to know just how long that period of time was going to be but it was likely to be some while.”
Ms Mutch added: “There was no evidence to suggest that there was any discussion with the family about how they should support Mr Gibbons in that room and whether it was safe or not for him to leave the room, even for the toilet.”
Having spent the afternoon waiting for a bed to become available, Mr Gibbons told his sister he was going to the toilet shortly before 5.30pm.
“Myself and Martin were then left in the mental health room for around two hours, with no idea of how long we would be there as there is a shortage of mental health beds,” Mrs Blair explained.
“The mental health team hadn’t notified any of the NHS staff of the severity of his state, no one was told to check on us, I was not informed that the mental health room has a panic button that runs right the way round it should I have wanted to raise an alarm.”
Mrs Blair explained that Mr Gibbons told her he needed to go to the toilet and she had gone to check on him and bumped into him in the corridor.
Twenty minutes later, he said he was going to the toilet again. She went to check on him again about a minute later and he was not there.
Ms Mutch told the court: “At the time of his death, there was a failure to conduct a detailed risk assessment in the period while a bed was sought or to agree a joint plan to manage the risk.
“It is probable that failure contributed to his death.”
While Ms Mutch was presented with evidence to indicate that procedures and new documents had been implemented within the two trusts, including a clearer definition of how someone is deemed to be of ‘high risk’, she feared it was not enough on a ‘national’ level.
As a result, Ms Mutch said she would be making a report to prevent future deaths directed to the Department of Health and Greater Manchester Health & Social Care Partnership.
The senior coroner said the report would identify the need for a ‘documented risk assessment and a documented share care plan between acute and mental health trusts’.
It would also look into the issues around mental health bed shortages and a ‘responsibility’ of care.
Ms Mutch explained: “There was a very clear message from all the mental health witnesses who gave evidence that the issues of beds are ongoing in terms of patients such as Mr Gibbons who need to be placed in those beds.
“Another issue is the fact that he was assessed by a mental health trust in that mental trust area but because he doesn’t live there, it’s another mental health trust that has to take responsibility for his care.
“That’s not an issue with the trust, they’re following a system, but that’s something that clearly isn’t right.”
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Source: Manchester Evening News, 23rd April 2021
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