A health authority has been criticised for poor staffing levels, shoddy note-keeping and inadequate training after a man was found hanged in a mental hospital after telling staff he might kill himself.
Neil Stanhope, 27, from Esher, was found hanging in a shower room of Halswell ward, Springfield Hospital, Tooting, on July 27, 2008, after being taken off 24-hour observation.
Mr Stanhope was transferred to the hospital after self-harming, the court heard, and was anxious about a medical tribunal hearing to determine if he was mentally ill.
On July 9, Mr Stanhope’s level of observation was reduced from 24 hours to every five minutes at his request, but the hospital did not change observation levels when Mr Stanhope told a nurse on July 18 he would hang himself if he was not discharged after the tribunal.
A jury at Westminster Coroner’s Court returned a narrative verdict on February 16, and said Mr Stanhope hanged himself, “while the balance of his mind was disturbed”.
It concluded the death was accidental, but criticised South West London and St George’s Mental Health NHS Trust for a series of failings that contributed to his death.
The jury heard it failed to complete a care plan for Mr Stanhope or to provide adequate reports for the ward round meetings.
It added there was inadequate supervision and training of nursing staff, poor note-keeping, insufficient communication between staff and a failure to report observations while Mr Stanhope’s medication was reduced.
On the day he died it said there were deficient observations and inadequate staffing levels on Halswell ward, adding there was “managements failure” to address staffing concerns reported to management, including from the ward charge nurse.
A spokeswoman for the trust said it had implemented several changes following the death and the trust’s chief executive and board had passed a new training scheme which included specific modules on risk assessment management and care planning.
She said there was better observation management and there was a permanent ward manager.
She said: “We extend our sincere condolences to the family and loved-ones of Neil Stanhope and our thoughts are with them at this difficult time.
“We recognise the criticisms placed on the service by the coroner in this case and have also identified shortfalls in Mr Stanhope’s care in our own internal investigation.”
Comments: Our rules
We want our comments to be a lively and valuable part of our community - a place where readers can debate and engage with the most important local issues. The ability to comment on our stories is a privilege, not a right, however, and that privilege may be withdrawn if it is abused or misused.
Please report any comments that break our rules.
Read the rules hereComments are closed on this article