A mental hospital where a young Doncaster man hanged himself says it will ‘act immediately’ after being criticised by a coroner for a lack of risk assessment and poor record keeping.
Grieving mother Tracy Lowe last night spoke out following the inquest into the death of 24-year-old Daniel Williams while a voluntary inpatient at St Catherine’s Hospital, Balby.
Tracy said: “Dan should never have died. Had there been effective communication between all staff and more in-depth assessment of his needs, his intent to take his own life would have been more fully appreciated.
“Whilst nothing can bring Dan back to us, we hope the Trust quickly reviews its care and communication so that no other family will have to suffer the distress we continue to feel.”
Doncaster Coroner Nicola Mundy is writing to management of St Catherine’s to raise her concerns about their ‘holistic approach’ to patient safety and ask for staff training to be reviewed.
The four-day inquest last month heard Daniel was found hanged last June with a knotted bedsheet around his neck despite him having given staff his sheet a few days earlier and making references to hanging himself.
Daniel, aged 24, of Farnborough Drive, Cantley, had serious mental health issues after failing to come to terms with being diagnosed as diabetic when he was only 18.
He found it increasingly difficult to adapt to the condition and did not engage with healthcare professionals who were trying to manage it. He took prescribed drugs and had also used cannabis and cocaine but descended into a ‘downward spiral’ which last May led to him taking an overdose of insulin which he thought would end his life.
After treatment he was admitted to St Catherine’s where he told a psychiatrist he had made several attempts at self-harm, including hanging, overdoses and putting a plastic bag over his head. He was initially assessed as being a significant risk of suicide but despite him making references to hanging himself at his next assessment, Ms Mundy said there was ‘insufficient detail’ in the assessment report and she added: “The notes were not representative of a developing clinical picture.”
A spokesman for Rotherham Doncaster and South Humber NHS Foundation Trust offered their ‘deepest condolences’ and said: “We have listened to the coroner’s comments and we will be acting immediately to address her concerns. We investigated the incident when it happened and we have carried out improvements to the ward.”