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Coroner finds that failures at the Royal Derby hospital contributed to death of patient

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Following the Inquest into the death of Ricky Hill the Coroner has today returned a narrative conclusion in which he found that a number of failings in care and management of Ricky by staff at the Royal Derby Hospital contributed to his death. Ricky Hill, a 30 year old man, went missing from the Royal Derby Hospital on 23 September 2014. The inquest was held at Derby Coroner’s Court from 23 June to 4 July 2016 before Dr Robert Hunter.

Ricky Hill, who had a recent history of depression, overdosing and carrying out acts of self harm, was taken by ambulance to the Emergency Department (‘ED’) at the Royal Derby Hospital on 22 September 2014. He was admitted to the hospital for assessment by the Mental Health Liaison team (‘MHLT’) and for treatment for an overdose. On at least two occasions 11.50pm and 3am a doctor recorded in his medical notes that Ricky had ongoing suicidal thoughts. In addition Ricky’s family had informed the staff on arrival at the hospital that he was likely to abscond and that they were very concerned about him. This was reiterated at the morning handover on 23rd September on the Medical Assessment Unit (“MAU”) at 7:30am despite this he was allowed to go out of the hospital building for a cigarette at about 8:10am; unaccompanied and unobserved. He subsequently went missing. Ricky was found dead in the grounds of the Royal Derby Hospital nearly four months later, on 10 January 2015, having taken his own life.

At the Inquest the Coroner heard evidence from staff who were working in the ED and MAU on the night when Ricky was admitted and also from senior management within the hospital as well as from an independent expert ,Dr Kullu, a consultant psychiatrist.

Having heard the evidence the Coroner concluded that, even though hospital staff were aware of Ricky’s ongoing suicidal thoughts and the high risk of him absconding, no structured risk assessments were carried out and no effective written care plan was put in place to minimise those risks.

In his conclusion the Coroner highlighted the fact that, although the hospital trust had guidelines in place which specifically related to assessing and managing the risk of suicide and self harm in patients, these guidelines appeared not to apply the ED and those that gave evidence were unaware of those guidelines.

Furthermore, despite on a daily basis seeing patients presenting to the ED and MAU with suicidal thoughts and self harming behaviour the staff had received no training on the assessment or management of these patients when they were awaiting a formal assessment by the MHLT. The staff who gave evidence also said that they unsure as to how to open up a conversation with someone who was suicidal and did not feel confident at the time of Ricky’s admission discussing suicidal thoughts with patients. The independent expert evidence heard from Dr Kullu was that an essential part of any risk assessment was to explore suicidal thoughts with a patient who presented as suicidal.

The Coroner also heard evidence concerning the failed attempts to find Ricky after he had gone missing, including the fact that the security department had an incorrect description of Ricky and this was not rectified for 7 days, making any initial searches of the hospital and grounds both in person and by CCTV futile. Further, while the police had a more accurate description they only had one officer carry out a drive round search of the hospital grounds. Later searches failed to identify the wooded area at the back of the hospital due to searches being delimited by the ‘perimeter fence’. It was not appreciated by the police nor the hospital security that this wooded area belonged to the hospital. It further transpired that the nurse who last saw Ricky was not spoken to until some 5 days after Ricky had gone missing which meant those searching for Ricky did not have a full understanding of where he was last seen despite searches by the police and specialist search teams Ricky was found by a member of the public on 10 January 2015.

The Coroner also announced that he would be making two Regulation 28 reports aimed at preventing future deaths. One to the Secretary of State for the Department of Health and one to the Chief Constable of Derbyshire Police and the Derbyshire Police and Crime Commissioner. The first report will relate to the need for Emergency Departments and medical assessment units to have in place policies, guidelines and procedures for conducting structured risk assessments and risk care planning.

The second report was to raise concerns about the way in which missing persons are dealt with by the police, and in particular concerns about officers not liaising with the security department at the Royal Derby Hospital, not attending to speak to the nurse on the ward who last saw Ricky, and the failure to identify the wooded area at the back of the hospital where Ricky was found as  an area to be searched. He was concerned that although the search was said to have been ‘intelligence’ led, he felt they approached the search in too rigid and didactic way. He also raised concerns about the lack of any briefing, and that the police had used out of date maps from Google, rather than requesting maps from the hospital.

Dawn Hill, Ricky Hill’s widow said following the hearing:

As a family we are pleased that the Hospital Trust has now recognised and admitted that there were failings in Ricky’s care, and that the Coroner has recorded these in a narrative conclusion. Our priority now is making sure changes have and will be made so that this does not happen to anyone else. We are therefore also pleased that the Coroner has announced that he will be making 2 reports aimed at preventing future deaths. If through this process one life is saved and one family is saved from going through what we’ve gone through then we will have succeeded in making sure that something positive comes out of the tragic loss of our much loved Ricky.’ 

The family was represented by Alison Gerry from Doughty Street Chambers and Rebecca Treece from Lester Morrill Solicitors.

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