33 year old Bernard Lee Phillips died on the 31st October 2015 having taken his own life shortly after attending North Manchester General Hospital in crisis. Bernard suffered from chronic bipolar affective disorder and had an additional diagnosis of emotionally unstable personality disorder. He had a history of self harm and suicide attempts and had attempted to take his own life on at least 8 occasions.
In times of crisis Bernard would stay with his mother until he felt better and she and his immediate family were a huge protective factor.
Bernard was supported in the community by the community mental health team and was assigned a Care Co-ordinator. Bernard was advised to attend Accident and Emergency in times of crisis to keep himself safe.
In October 2015, his mental health had deteriorated and he presented to A&E on three separate occasions in the week preceding his death. He was experiencing thoughts of and attempts to harm himself and thoughts to harm others.
On 26th October 2015, he attended A&E twice. He was assessed, reassured and thereafter discharged. Evidence was heard that it was clear that Bernard wanted to express his thoughts and access support when in crisis. On the morning of 29th October 2015, Bernard attended A&E a third time seeking support. He was not triaged for over an hour when he should have been triaged within 15 minutes. Out of frustration, he went into the toilet and self harmed. Bernard was found in the triage area by an A&E doctor with two knives which he quickly surrendered to the A&E doctor. He was treated for self harm wounds he had endured in the toilet and a mental health assessment referral was requested. Due to Bernard’s mild intoxication this was delayed. The mental health nurse did not document a discussion with the A&E doctor on the system that Bernard was in the department, had self harmed and was intoxicated. No care plan was implemented and Bernard left the department without being seen by a mental health nurse and did not attend an appointment that day to see his care co-ordinator as planned. The missing patient policy was not followed upon Bernard leaving the department which would have prompted checks of the ward being made, security being informed and Bernard’s family being contacted. Bernard’s family were not informed of the three attendances to A&E and were therefore unaware of the deterioration in his mental health. He was last seen at 11.20pm on 29th October 2015 and was sadly found hanging at his home address on 31st October 2015.
Assistant Coroner Miss Harkins concluded that having heard the evidence surrounding Bernard’s death, she was not satisfied that he intended to take his own life. She found that there had been a number of systemic failings by A&E staff and Mental Health staff at the hospital and as a result of these failures he did not receive the support that would have provided treatment, reassurance and transfer of information that would probably have prevented his premature death.
Internal investigations carried out by Pennine Acute Hospitals NHS Trust and Manchester Mental Health and Social Care Trust revealed missed opportunities in Bernard’s care and the inquest heard evidence that a number of changes are in the process of being implemented by both Trusts. On behalf of the family, HM Coroner was alerted to the findings and reports made by HM Senior Coroner, Mr Meadows, in the earlier inquest of Nicholas Sullivan who took his own life shortly after attending the same hospital in 2014 in crisis. Similar concerns were raised in that case about the failure to triage and assess Mr Sullivan when he attended A&E.
The family expressed disappointment that despite being alerted to these previous concerns the Coroner decided not to use her power to make a prevention of future death report which would require PAT and MMHSCT to notify her and the Ministry of Health of the changes that have been made within 56 days. The family are clear in their desire that they do wish Bernard’s death not to have been in vain and hope that the failings are immediately rectified.
The family were represented by INQUEST Lawyers Group members Kelly Darlington, Farleys solicitors and Anna Morris, Garden Court Chambers.
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