Mr E, full name anonymised for privacy and confidentiality reasons, was detained under section 3 of the Mental Health Act (1983) at the mental health unit in Aderyn Hospital under the care of Elysium Healthcare. On 11 November 2022, he was declared deceased.
Mr E’s father sought legal representation from Southerns Solicitors following the unexpected death of his son in a hospital setting. The inquest was held to determine the circumstances of the death and whether any failings had occurred in the care provided.
A summary of the death of Mr E
Mr E was a vulnerable man who suffered from longstanding mental health conditions which led to a lengthy involvement with mental health services including numerous inpatient admissions.
He was admitted to Aderyn Hospital on 8 August 2022.
Mr E had a known history of attempting to make concoctions of plantation and other substances which he would often try to ingest. On several occasions, he spoke about wanting to grow or buy items that could be used for making mind-altering substances. For example, he had spoken about wanting to grow poppies and hemp. During his time at Aderyn, he also occasionally displayed delusional beliefs and presented with aggressive behaviour.
Despite this recorded behaviour, the hospital granted Mr E Section 17 unescorted leave. He was initially shadowed to minimise the risk of him absconding and ingesting substances. However, after he gave assurances that he would not carry out such acts, unescorted leave was permitted.
On 11 November 2022, at 20:10, Mr E was found unresponsive shortly after returning from his unescorted leave. Despite resuscitation attempts being made by paramedics, he was sadly declared deceased at 12:02. It was later established that Mr E had ingested plantation/vegetation from a Yew Tree, inside the hospital grounds.
Client seeks Southerns Solicitors for Legal Representation
Mr E’s father was extremely concerned about how his son was able to ingest leaves from a poisonous tree.
Firstly, why was a tree, which is known for its toxicity and therefore a threat to life, allowed to remain in an area where vulnerable patients could access it?
Secondly, why did staff, who knew of Mr E’s behaviours and tendencies to ingest vegetation allow him to access the tree without being monitored?
Mr E’s father therefore sought legal representation to help him get the answers, and ultimately hold those responsible accountable after the inquest had concluded.
Initially, we were tasked with persuading the Coroner to trigger Article 2. An Article 2 inquest is an enhanced inquest, required when the state has a duty to protect life and potentially failed to do so, such as in cases of death in custody or under state care, or where there are concerns about systemic failures. An enhanced inquest goes beyond the standard investigation of “who, when, where, and how” a person died.
After written submissions were made, the Coroner engaged Article 2 at a Pre-inquest Review Hearing.
Article 2 Inquest Hearing
During the inquest final hearing, a contentious issue between the family and Elysium Healthcare was the guidance the Coroner should provide to the Jury to help them reach an appropriate conclusion.
Counsel for the family, instructed by Southerns, made strong oral submissions that a narrative conclusion appeared the most suitable conclusion. The jury was permitted by the Coroner to give a narrative conclusion which they duly did.
It is important to understand that an inquest is different from a civil or criminal trial. It is not about deciding issues of guilt, blame or negligence. It is purely a fact-finding process.
Coroners and Juries are permitted to address failings in their conclusion but it must be worded very carefully so as to avoid any indication of blame. Families often struggle with the notion that inquests are fact-finding, not fault-finding, but inquests can play a very important role in establishing whether there are prospects of a civil claim being pursued thereafter.
Outcome
The Jury found that Mr E’s accidental death was contributed by Elysium staff’s failure to identify and manage his risks of ingesting plantation.
Additionally, the coroner issued a Regulation 28 report to Elysium. Regulation 28, also known as a Prevention of Future Deaths (PFD) report, is a mechanism used by coroners to raise concerns about ongoing risks identified during an inquest, requiring action to prevent future deaths. The coroner issued this PDF report due to her grave concerns in respect of how information was recorded and the repeated failure by staff to ask Mr E questions during and after leave to help clinicians assess his ongoing risks.
Mr E’s father was extremely pleased and relieved the jury had recognised Elysium failed to properly protect his son from the dangers which were contained in the hospital grounds. The failings will now allow him to consider a civil claim for financial damages and seek further justice for Mr E following his untimely passing.
The inquest into the death of Mr E highlights the consequences that can arise when hospital staff fail to properly assess and manage patient risks. The finding that their care contributed to his accidental death serves as a stark reminder of the duty of care owed to vulnerable individuals.
While no legal fault is determined in an inquest, the conclusions can play a crucial role in uncovering the truth, ensuring accountability, and driving improvements in patient safety.
If you have lost a loved one and need expert legal support for an inquest, our experienced solicitors are here to guide you through the process with compassion and expertise. Visit our Inquest Representation page to learn more about how we can help.
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