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Exeter Express and Echo
Popular East Devon teenager George Werb died after standing in front of a train was suffering from depression, inquest hears | Exeter Express and Echo
A talented and popular East Devon teenager died after standing in front of a high-speed train after suffering from severe mental illness and depression, an inquest has heard. George Werb, 15, from Colyton, was killed he was hit by the train at around 6.50am near Seaton Junction on Friday, June 28, last year.Popular East Devon teenager George Werb died after standing in front of a train was suffering from depression, inquest hears | Exeter Express and Echo
The inquest at Exeter’s Coroner’s Court heard that George had left a three page suicide note under his bed which was discovered shortly after the tragedy occurred and his parents, Joanne and Justin Werb, felt his suicidal tendencies were often not taken seriously enough by staff at the Priory Hospital in Southampton where he was been a patient in the weeks prior to the tragedy. In a statement read out to the court, the train driver said he had applied the brakes and emergency brakes immediately on seeing someone walk “calmly and deliberately” onto the tracks in front of the train.
The court heard that after being referred by his GP, George waited around 10 months until his first appointment with a Child and Adolescent Mental Health Services (CAMHS) team member in Exeter. It was a subsequent visit to his GP who referred George back to CAMHS and Doctor Seth diagnosed him as suffering from psychosis involving persistent delusion disorder with depression, which he described to the court as “exceptionally uncommon”. George’s father explained that the family had noticed a change in George around 18 months before his death, and had witnessed him going from being outgoing and involved in numerous extra-curricular activities including acting, playing musical instruments and karate, to becoming withdrawn. George was initially prescribed anti-psychotic medication which the court heard he refused to take after three doses. George’s father explained that they noticed a “massive” change in their son from the point he started taking the medication. The court heard that George was extremely distressed at having taken the medication, having researched the effects on the internet, a trait that persisted in line with his condition, from then on. He was subsequently advised he needed hospitalisation to ensure his safety and for ongoing assessment and treatment. Dr Seth told the court that at the time, he would have to phone 20 – 30 units to find out where there is availability for a new patient because there is a shortage of beds. The closest unit was Plymouth but there was no room so the closest hospital with availability was at Huntercombe Hospital in Maidenhead which George’s parents removed him from after visiting him three weeks later. They said his room was “not fit for a dog”, his bed had no sheets on it, the curtains were short, he still living out of his suitcase and he looked disheveled and unclean, and discovered another patient had threatened to kill George. After returning home for a short period, George was sectioned and admitted to the Priory, where staff were “very kind”. Giving evidence, George’s parents spoke of their dissatisfaction over the lack of communication from hospital staff particularly that, they say, they were not advised that suicidal tendencies could increase as a possible side effect of the anti-depressants he was soon prescribed. The court heard that George has tried to take his life at the hospital but his parents weren’t immediately informed. And when his mother Joanne informed staff her son was suicidal, after his first weekend visit home, there were no formal meetings to discuss the issue nor any real attempt to engage with them and keep them informed. However consultant psychiatrist at the Priory, Dr Hoyos refuted this point and said he was not informed of George’s worsening suicidal thoughts by his parents, only the issue of George’s medication making him worse. George’s mum told the court her son seemed happy in the early days at the hospital but wasn’t happy about the anti-psychotic medication being resumed. She said her son told her he would sometimes spit out his medication so it was changed to a melt in the mouth tablets. The court heard that George had drawn pictures of scenes depicting his suicide. She requested that Dr Hoyos reduce his medication but the court heard that he refused, believing it to be a crucial part of his treatment. He prescribed George anti-depressants at which point his suicidal tendencies worsened, however Dr Hoyos explained that there is no significant evidence that the particular anti-depressants George was prescribed caused suicidal tendencies. George’s father told the court that when he returned home for a weekend he was “far from well” and when he visited him at the Priory his son looked “hideous” and thought his son was getting worse. After dropping George off at the Priory on the Sunday after his first weekend visit, his mum was given permission to pick her son up on the Thursday and take him home for a second home visit where they had a busy and pleasant family evening ahead of his tragic end the following morning. The court heard that Dr Hoyos did not keep regular written clinical notes, which is being looked into by the General Medical Council, but he said this did not affect patient care. He said that normal procedure after a patient’s home visit is for a nurse to find out how the visit went and report back to him. He said it was “important” that the family was engaged with the unit. At the time of his death, the headteacher of Woodroffe School in Lyme Regis where George was a pupil paid tribute to the youngster describing him as “talented” and “hard-working”. On a Facebook page set up for his friends to express their grief for George, friends described him as a “sweet boy”, a “loving, talented young lad” and “an amazingly gifted and talented boy who was well loved”. The inquest continues tomorrow, Tuesday, October 7.
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Coroner highly critical of care provided to 15 year old boy at Priory Hospital, Southampton
09 Oct 2014
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.”