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This is Gloucestershire
Friday, January 30, 2009, 06:25
A maintanence engineer who had become suicidal was able to jump to his death from a hospital window because of errors of judgement made by medical staff, a coroner ruled yesterday.
Father-of-two Andrew Berry, 47, had been rushed into Gloucestershire Royal Hospital after taking an overdose of sleeping pills and anti-depressants at home.
The accident and emergency officer, Dr Charlotte Whitehouse, who first saw him, rated him as a ‘medium risk’ of harming himself.
As a result of the risk assessment he was transferred from the ground floor to a second floor ward in the hospital for the night because a mental health nurse had not had time to see him and make her own assessment.
Shortly after arriving in the ward on April 4, 2007 Mr Berry smashed a window by throwing a TV at it and jumping out.
Mr Berry, of Ridgemount Close, Brockworth, fell to the ground below and died from multiple injuries despite the efforts of doctors and paramedics who ran to his aid.
Gloucestershire coroner Alan Crickmore said he was satisfied Mr Berry killed himself.
He went on to record a narrative verdict in which he said there had been opportunities to prevent the tragedy but they were missed.
The coroner said if Dr Whitehouse had rated Mr Berry as a high risk of self harm, he would not have been moved to an upper floor from which he could jump.
And if the mental health nurse Amanda Davies had not been too busy to assess Mr Berry that day she might have recognised his true risk of self harm, said Mr Crickmore.
There was also a failure to inform Mrs Davies properly about Mr Berry’s medical state.
“I do not think I can say that the failures which have been identified can properly be characterised as gross failures,” said the coroner.
“The root cause of the opportunity to jump was his assessment as a medium risk of self $and this was a matter of clinical judgement by Dr Whitehouse.
“Everyone else then relied on her judgement. With the benefit of hindsight I think she was wrong – but she was justified in reaching the decision she did. There was no gross failure.
“He was assessed as a medium risk of self harm by a relatively inexperienced doctor in the accident and emergency department of the hospital who had received no training in relation to the completion of the self harm assessment document then in use.
“Mr Berry’s subsequent planned assessment by the mental health liaison practitioner was delayed beyond the period of time designated in the self harm assessment document because the practitioner had more patients to see than her working day allowed.”
He said the mental health practitioner accepted the medium risk assessment made by Dr Whitehouse, acted on inaccurate information about Mr Berry’s medical status and, because of her working hours, lacked time to see him.
She then prioritised another patient who was rated high risk but was medically fit and wanted to leave the hospital.
“At no time was any further self harm assessment carried out, in particular by any person properly qualified to judge their risk,” said the coroner.
“Mr Berry’s true risk of self harm was never recognised, as a result of which he was transferred to a ward on an upper floor of the hospital.”
A spokeswoman for Gloucestershire Hospitals NHS Foundation Trust said: “We would like to extend our deepest sympathies to the family of Mr Berry for their loss.
“We do accept the Coroner’s findings. Since Mr Berry’s death we have made a number of significant changes to the way patients at risk are assessed and treated, and to the support services that we provide to help them.
“The number of mental health practitioners that are available to assess patients has been increased and the service is now provided seven days per week with extended hours. In addition, patients who are assessed as ‘medium risk’ now remain on the Acute Assessment Unit and are not transferred to another ward unless one-to-one nursing care is available.
“Ensuring the safety of our patients is of paramount importance to us and we are committed to working closely with our partners in the mental health trust for the benefit of patient care.”