As lawyers, we hear too many stories of patients with mental health problems being let down by private and NHS care, often with tragic consequences.
Protecting the vulnerable
As a society, we have a duty to protect the most disadvantaged and most vulnerable among us. But funding cuts, insufficient training and hospital resources already stretched to breaking point mean we too frequently fail those reliant on the state for help when they are at their lowest. Families are left devastated by the terrible aftermath of those failings.
I am currently acting for the teenage daughters of a man who hanged himself while in the care of medical staff at Rochford Hospital in Essex. Following Steve Adams' death, the hospital's own internal report highlighted a number of systems failures and a damning lack of communication between staff caring for Mr Adams, who had been sectioned precisely to protect him from self-harm.
Mr Adams was taken into the care of the hospital when he was discovered by police in his car deeply disturbed and clearly saying he wanted to end his life.
Failure to protect
While he was in the assessment unit, he attempted to hang himself using his bedsheet but was interrupted by a nurse who talked to him and prevented him from seriously injuring himself. Shortly after the incident Mr Adams was detained in state care for his own protection and admitted to the hospital. However, his suicide attempt that morning was not properly recorded or handed over to the ward and Mr Adams was left alone long enough to kill himself.
What makes this story worse is that Mr Adams was not simply lost in the community; he had been specifically identified by the police and doctors as someone who desperately needed help. It was obvious he was in a very bad state and deserved the full attention of medical staff.
During the inquest in front of a jury, the coroner flagged up the problems with hospital procedure that meant that most of the medical staff caring for Mr Adams didn't even know about his recent suicide attempt, his risk had not been properly assessed and there was no care plan in place for him. Had they known, it was admitted this would have affected the care he received.
Damning evidence
The support workers caring for Mr Adams immediately before he hung himself said that they would not have let him out of their sight and certainly wouldn’t have left him alone in the bathroom had they known about his previous attempt to hang himself 2 days earlier. The evidence heard during the inquest revealed a long list of serious problems that together proved catastrophic for Mr Adams.
Mr Adams' 19-year-old daughter, Jade, was brave enough to give evidence to the jury. Her belief that her father cared too deeply for her and her sisters to have fully intended to take his own life was echoed by jury's decision to record a conclusion of accidental death, rather than suicide.
This at least will bring some relief to three young women who have lost their father in terrible circumstances, circumstances that should never have been allowed to occur had their father received the appropriate level of care.
After hearing three days of evidence the jury concluded that the Trust had failed to adequately assess Mr Adam's risk of self-harm or suicide and had failed to take steps to protect him from that risk. Many of those failings were basic, simple things and the absence of any one of them may have saved Steve's life and let him go on to have the treatment he deserved.
Letter to the coroner
In a letter to the coroner, Jade Adams described how she thought her father had settled into hospital well, but now knew was very far from the truth.
"I know he had attempted suicide many times before he was admitted and I simply don't believe the hospital addressed this. They basically left him to his own devices when he was at his lowest and most needed help. We trusted them to protect him and help him get well," she said.
"My sisters and I are devastated by his death and feel very let down by the hospital. They were meant to keep him safe until we could all work together to get him better."
Just before the inquest, the hospital trust admitted a breach of duty of care and that, but for that failure, it is likely that Steve Adams would not have died on that day.
Nothing can bring their father back but I will now work with Jade and her sisters on a civil claim that will hopefully help them cope with the future.
Steve Adams' daughters were keen to publicise their father's story in the Evening Standard in a similar hope to the Royal Princes - that highlighting the need for proper care of mental health patients remains in all our consciences and impacts future funding policy.
Steve Adams' story was featured in the Evening Standard.
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