The 'devastated' widow of a man found hanging on a mental health ward in Sheffield has called for lessons to be learned from the tragedy.
Gillian Dransfield believes her late husband Keith, a 70-year-old accountant and grandfather-of-two with whom she lived in Wincobank, would still be here today had staff listened properly to his family's concerns.
She spoke out after jurors at an inquest into Mr Dransfield's death found the level of care he received fell short of an appropriate standard.
"Less than a year on from losing Keith, the entire family remains completely devastated. It is still very hard to believe he is gone," said the 57-year-old.
"His death has been made even harder to take knowing that he should have had far better support and care.
"We raised concerns about Keith’s condition and how he appeared to be getting worse, but we feel that our concerns were not listened to. We believe that if they were listened to, then
Keith would still be alive today.
“Nothing will ever change what has happened, but we simply want to know that steps have been taken to ensure that no other family faces the ongoing and devastating heartache that
we have had to endure."
Mr Dransfield attended A&E at Northern General Hospital on September 25 last year, having experienced suicidal thoughts following a rapid deterioration in his mental health.
He was detained under the Mental Health Act at The Longley Centre, which is run by Sheffield Health and Social Care NHS Foundation Trust.
Staff initially checked up on him every 10 minutes, but the frequency of observations was reduced despite his family raising concerns with staff about his deteriorating condition.
He was found hanging in his room on September 29 and, having been starved of oxygen, died the following day from a brain injury.
A six-day inquest into his death ended yesterday at Sheffield Coroner's Court, with jurors recording a narrative conclusion.
Jurors concluded that the reduction in the frequency of observations had not been justified, and that staff had not been properly trained and did not consistently consult the written records of patients allocated to them.
They also found that the frequency of Mr Dransfield's observations should have been increased to every 10 minutes, and that had this been done he would have been more likely to have survived.
In light of their findings, coroner David Urpeth has issued a report designed to prevent future deaths.
An investigation by the trust previously found a 'root cause' of Mr Dransfield's death to be staff underestimating the risk he posed to himself, along with a ‘lack of robust assessment.’
Sinead Rollinson-Hayes, expert medical negligence solicitor at Irwin Mitchell, who represented the family at the inquest, said: "Both the NHS trust report and now the inquest have raised significant concerns regarding the care Keith received, so it is clear that reassurances are needed that lessons have been learned following his death.
"Patients and their families put great faith in the NHS that an appropriate standard of care will be provided, but sadly that was not the case here."
Kevan Taylor, the trust's chief executive, offered Mr Dransfield's family his 'sincere condolences' and assured them action was being taken.
He added: "Our investigation highlighted a number of areas where the delivery of care could have be improved and a comprehensive action plan is in place in which all of the recommendations have either already been addressed or are in progress...
"We are determined that as a result of this extremely sad event we offer a safer, more supportive service for everyone who uses our in-patient services."