Assistant Coroner, Lydia Brown, criticised the Priory Hospital, Southampton, and Consultant Psychiatrist Dr Carlos Hoyos, for the care provided to 15 year old George Werb, in June 2013, resulting in his death on 28 June 2013. She was also critical of mental health provision in the UK and especially the fact that some children are placed in units hours away from the family home.
In recording a narrative verdict, the coroner noted that Dr Carlos Hoyos, the Consultant Psychiatrist in charge of George's care made no clinical notes and had to rely on his recollections in giving evidence. The coroner found that she was unable to place much reliance on such recollections and instead preferred the evidence of Mr and Mrs Werb, who had written down their concerns that George was suicidal following a period of home leave.
Unfortunately, the parents' concerns were not acted upon, and despite a nurse also recording that George was very suicidal on 24 June 2013, a decision was made to allow George on home leave on 27 June 2013 without an up to date risk assessment being carried out, and hours after he had been prescribed an anti-depressant, Fluoxetine, which has a known short term side effect of potentially increased suicidality.
The coroner found that before home leave commenced, George was assessed as having no suicide risk. The information used in this assessment was incomplete, inaccurate and did not reflect the actual situation. A member of staff had in fact suggested that the proforma risk assessment document for suicide risk be changed from "no" to "yes" prior to George departing on home leave, but such action was not taken.
The coroner refuted any suggestion that George's parents would have taken George home on 27 June 2013 had they been in possession of all the available information and noted that they had placed their trust in the psychiatric services. In commenting on Dr Hoyos' assertion that he felt the parents did not trust the psychiatric services, she stated "frankly, who could blame them. The parents were doing their best to care for George; they had a right to expect the same of the services they entrusted their son to."
The coroner was unable to conclude that George had committed suicide as at the time of his death he was hearing voices which may have told him to take his own life. George died at approximately 06:50 on 28 June 2013 when he calmly stepped out in front of a train near Seaton Junction in Devon, just 45 minutes from his family home.
The coroner is calling for an inquiry by NHS England and the Department for Health following this inquest. The GMC are also investigating Dr Hoyos.
Mark Bowman, the family's solicitor commented on their behalf:
"The findings that the information used to assess George's suicide risk were incomplete, inaccurate and did not reflect the actual situation, is upsetting and we believe George would still be here had things been different. To lose our son of only 15 years, who had so much more to accomplish and experience is totally heart-breaking."