Negligent failures in communication contributed to father's death | Fieldfisher
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Case Study

Negligent failures in communication contributed to father's death

Following an inquest in front of a jury at Chelmsford Coroner's Court, Arti Shah achieved settlement in a negligence claim on behalf of the children of Steve Adams who tragically killed himself while being cared for in a specialist mental health unit at Rochford Hospital, Southend.

Mr Adams had been found by police on the evening of October 19 sitting in his car, saying he wanted to end his life. He was sectioned under the Mental Health Act and admitted to the Cedar Ward, which provided acute adult care.

The following morning, Steve made a suicide attempt, but was stopped by a member of staff. However, details of the incident were not passed on to other hospital staff. Later that day, he made another attempt and was found unconscious. Appropriate observations had not been made in the two hours previously. Steve died two days after the attempt.

Steve's death was reported to the Coroner, who unusually in these types of cases, decided to hold a jury inquest. Evidence was heard from Mr Adams' daughter, as well as the staff involved in his care over three days.

In her summing up, the Coroner flagged the problems with hospital procedure that, for one, meant that most of the medical staff caring for Mr Adams did not even know about his recent suicide attempt, affecting the care that he received. It was recognised that there had been a failure to adequately assess or review Mr Adams' risk of self-harm or suicide, and that the Trust had failed to take appropriate precautions to protect him from his risk of self-harm or suicide.

The jury agreed, and concluded Steve's death as being "accidental" as opposed to suicide. Mr Adams' children have always believed that their father had not intended to take his own life.

The hospital undertook its own investigation into the care provided to Steve, acknowledging the findings of the Inquest conclusion. It produced an internal report, which recognised failures to communicate Mr Adams' previous attempt at suicide at handovers between staff, and the failure to undertake a risk assessment or complete a care plan by the admitting nurse. Procedures did not appear to be followed as laid out in the Trust's own guidelines for clinical handovers. The admitting nurse was the subject of a Fitness to Practice Tribunal hearing, where those failings were also upheld.

Essex Partnership University Hospitals NHS Foundation Trust, which ran the hospital, admitted negligence, accepting that the failure to hand over information about Steve's suicide attempt was a breach of duty of care, and that had such information been provided, Steve would not have died.

Arti negotiated settlement for Mr Adams' three children who were aged 19, 17 and 15 at the time of their father's death. She obtained expert evidence from a Consultant Psychiatrist, who reported that Steve had previously enjoyed and maintained a long term relationship, and had been actively involved in bringing up his daughters. He worked for most of his life, and was actively involved in the community, particularly in Church groups. Had he received appropriate care, Steve would have gone on to make a good recovery, albeit while requiring support at difficult times.

Jade, Steve's eldest daughter said, "The last time I saw my father, he seemed to be in a much better place, although when I spoke to him three days before his death, he was upset and agitated."

She said she was 'hugely relieved' that the case was settled and the family commented:

"I just wanted to say a big 'thank you' for all your hard work with this case, you have certainly helped my family and for the girls' future. I am very grateful. We can’t thank you enough for your help in our dad's case. We definitely could not have done this without your support, and if we can be of any help in any way to recommend you, we would be happy to."

Contact us

For further information please call Arti Shah on 03304606739 or email


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