By Charlotte Webster-
The NHS care provided to a man in Colchester, who took his own life on Christmas Day, amounted to neglect and contributed to his death a coroner has determined. The inquest into the death of Michael John Woods – known as Mick – found there were a number of “missed opportunities” to prevent his death at the Henneage mental health ward in Colchester University Hospital in 2020.
The inquest, which opened in early 2021, concluded on Monday at Essex Coroners’ Court in Chelmsford. Area Coroner for Essex Sean Horstead advised that the number of missed opportunities “individually and cumulatively more than minimally contributed to the death of Michael Woods”.
Mick was in the care of the Essex Partnership University NHS Foundation Trust (EPUT) – previously the NHS North Essex Partnership Trust which merged with South Essex Partnership Trust to form EPUT in 2017.
The NHS North Essex Partnership Trust was fined £1.5 million in June 2021 for safety failings after the deaths of 11 patients in their care between 2004 and 2015, following a prosecution by the Health and Safety Executive.
The prosecution had pointed to the existence of fixed potential ligature points as breaches of safety laws. Despite EPUT pleading guilty in November 2020, Mick was able to take his own life with the use of a ligature in December 2020.
The Trust’s “missed opportunities” to prevent his death included an inadequate risk assessment both at the point of admission to the Henneage ward on December 10, 2020, and on an ongoing basis thereafter – this amounted to repeated missed opportunities to recognise that there was a high risk of self-harm, particularly with regard to ligatures. Alongside those instances, staff also failed to rescue Mick when he was found on Christmas Day, as a result of an inadequate emergency response.
When Mick was found at 9pm that day, staff failed to deploy a mask when using the Bag Valve Mask (BVM) apparatus (a device used on patients who have stopped breathing).
The inquest heard that this constituted an unacceptable delay in providing appropriate ventilation. The appropriate use of the BVM apparatus is something that is expected of a practitioner who has achieved competency in basic life support — mandatory training in a hospital setting.
The failure to use the mask to administer oxygen in a timely manner in these circumstances was an elementary error and a failure of basic medical and nursing care and, according to the coroner, also amounted to neglect.
Taken together, the missed opportunities constituted omissions on the part of medical practitioners forming part of a total picture which amounted to neglect. The coroner is considering whether to make a Regulation 28 Prevention of Future Deaths Report.
Groups to contact for those who need help:
Samaritans: Phone 116 123, 24 hours a day, or email jo@samaritans.org, in confidence.
Childline: Phone 0800 1111. Calls are free and won’t show up on your bill.
PAPYRUS: A voluntary organisation supporting suicidal teens and young adults. Phone 0800 068 4141.
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