The parents of a young man who killed himself on train tracks in Salford are calling for lessons to be learned after a coroner found that gross failings by a mental health trust contributed to his death.
Identified failures by mental health team include:
At the beginning of the inquest, GMMH admitted that while Alex was on Eagleton Ward there had been failures to:
Involve and engage Mr Turner’s father in risk formulation and risk management planning
Fully record information which was significant to risk assessment and management
Ensure that risk information gathered by [the trainee psychologist] was disseminated to staff on duty
Fully assess the escalating risk of Alex harming himself on December 5 and 6, 2019
Formulate a robust risk management plan to address the escalating risk on December 5 and 6, 2019
lex Turner, 24, from Chorley, went missing from the Eagleton Ward of Salford Royal Hospital’s Meadowbrook Unit, on December 5, 2019.
His body was found near Eccles station the next morning.
The Bolton inquest was told Alex had been diagnosed with an emotionally unstable personality disorder shortly after being admitted as a voluntary inpatient to North Manchester General Hospital’s Safire unit on November 24 following multiple suicide attempts.
The warehouse worker had been a cannabis and cocaine user over a period of five years.
Alex told staff that he heard a voice in his head telling him to kill himself, and his father raised concerns of a similar nature if he was discharged.
Alex had repeatedly told staff that he would kill himself, the hearing was told.
Despite this, assistant coroner Catherine Cundy heard that Alex was discharged without his family being told on November 28.
Within hours, Alex was admitted to the Eagleton Ward after council staff called an ambulance due to concerns that Alex would take his own life.
At the beginning of the two-week inquest at Bolton Coroner’s Court, Ms Cundy read out a series of failings admitted by Greater Manchester Mental Health NHS Foundation Trust (GMMH), including that there had been ‘a failure to formulate a comprehensive discharge care plan for Mr Turner’s discharge from SAFIRE Unit’ and ‘a failure to fully involve and engage Mr Turner’s father in the discharge’.
During his time on Eagleton Ward, Alex reported suicidal thoughts. On December 2, he told a consultant psychiatrist that he was hearing a voice in his head telling him ‘to go to the bridge’ and that ‘he was going to throw himself into a train but his girlfriend asked him not to’. Later that day, he told a nurse that he had ‘tried to jump off a bridge’ but had been stopped by his girlfriend.
According to medical records read out at the inquest, during a two-hour appointment with a student nurse on December 5 Alex ‘reported that he had suicidal ideation and he wanted to be put on a section as he was unable to keep himself safe in the community’. The court heard he became distressed and shouted that the devil was telling him to kill himself.
The inquest heard that GMMH telephoned Greater Manchester Police (GMP) shortly after midnight on December 6 when Alex failed to return to the ward.
Despite staff telling GMP that Alex, of Cross Kings Drive, Whittle le Woods, had previously attempted to climb over the Stott Lane railway bridge, it was not until 3.45am that GMP contacted British Transport Police (BTP).
A GMP search coordinator told the court that he expected that his colleagues would ask BTP to search the tracks within a 300 metre radius of the ward, which included the tracks under the Stott Lane bridge, but no such request was made.
The court heard that the BTP control room breached its own procedures by failing to ask what GMP wanted them to do, before grading the call as low risk requiring no further action. Shortly after 5am Alex’s body was found on train tracks under the Stott Lane bridge.
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Source: Manchester Evening News, 20th October 2021