NHS bosses in Sheffield have carried out an internal investigation after mental health patient, Jon-Paul Smith, was ‘inappropriately discharged’ from the Maple ward at Northern General Hospital.
The internal investigation by Sheffield Health and Social Care NHS Foundation Trust found that ‘care delivery’ could be improved.
Mr Smith was discharged from hospital a day after his family had visited him. They described his behaviour to the inquest as ‘erratic’.
Mark Walton, discharge co-ordinator on the Maple ward, told the jury he stood by the decision to discharge Mr Smith.
He said: “We felt it was safe and that we had seen a distinct improvement in Jon-Paul’s mental state and his presentation had been better.”
Mr Smith’s family also said they made it clear they wanted to be involved in any decision to discharge him.
But nine jurors found that Mr Smith’s discharge was ‘not appropriate’ and there was a ‘lack of involvement’ with the family.
Kevan Taylor, chief executive of Sheffield Health and Social Care NHS Foundation Trust, said: “The Trust would like to offer our sincere condolences to the family of Mr Smith.
“We have conducted our own thorough internal investigation into the circumstances leading up to the incident.
“This highlighted some areas where the delivery of care could be improved. We are currently working on the recommendations made by the investigation.
“The internal investigation findings have been shared with the family.”
Coroner, David Urpeth, also asked the Crown Prosecution to consider re-opening the case into Mr Smith’s death.
The CPS said it was too early at this time to comment.