AN INQUIRY has been launched into the care of a Sheffield man who shot himself in the head a month after being allowed home from a mental health unit.
Relatives of 68-year-old David Gregory said he was let down by medics who discharged him from hospital "too soon".
They also criticised the outpatients appointment system used by Sheffield Care Trust, which failed to book a follow-up consultation for the pensioner, leaving him languishing at home without anyone checking on his progress.
During an inquest into his death it emerged a nurse had faxed the unit's outpatients clinic to arrange an appointment but the request form was never received meaning Mr Gregory slipped through the net.
He was initially admitted to a psychiatric unit in Nether Edge after developing severe depression and anxiety over his failing health. He became paranoid and was having hallucinations.
Mr Gregory had been in good health most of his life but began suffering heart problems in 2006 and became convinced he was going to die.
When discharged from the unit in March Mr Gregory shot himself with a .22 rifle he kept in his loft at his home on Basegreen Crescent, Basegreen.
He left a note for his wife Helen, 69, at the bottom of the stairs asking her to call the police.
A note beside his body said he was "sorry" but he had taken his life because he was in "too much pain". He said he loved his wife and three sons and asked for forgiveness.
Fiona Goudie, Sheffield Care Trust's Clinical Director for Older People's Functional Mental Illness and Community Services, admitted the appointment system used had been flawed and said an "internal inquiry" was underway.
She said "interim" arrangements had been put in place to improve the outpatients appointment procedure and an electronic system would be put in place to ensure all patients leave hospital with an appointment on the day they are discharged.
She said: "It would eliminate this unsatisfactory paperwork system."
Consultant psychiatrist Jeremy Seymour said he had wanted an outpatients appointment made for two or three weeks after Mr Gregory's discharge to check he was still improving and taking his medication.
Answering questions from his wife Mrs Gregory, he said "in retrospect" he would not have discharged her husband so early but had not believed him to be a suicide risk.
He also said he "had no knowledge" that Mr Gregory had access to guns
"If you feel people are suicidal you would want to keep them in hospital and monitor them. We felt, wrongly, that your husband's problem was his fear of dying," he said.
Addressing Mr Seymour, Mrs Gregory said: "When you discharged him he felt there was no hope, that no-one wanted to know.
"He was frightened to death of going crazy and ending up in an institute – he could not live like that."
She said her husband stopped taking his medication at home because he claimed it had "poisoned his system".
Mrs Gregory also said she knew he had guns in their house but never thought he would ever use them to kill himself, although he had "joked" about it in the past.
Speaking afterwards she said the new appointment system was "too late" to save her husband, but should prevent other families suffering.
"If the appointment had come through I would have made him go and problems would have been picked up," she said.
Her son Tim, 40, added: "There should have been regular follow-ups, even on a week by week basis, where they could have checked to make sure he was taking his medication."
Kevan Taylor, Chief Executive of Sheffield Care Trust, said: "We accept the findings of the inquest which did raise concerns about an aspect of our referral procedure.
"Following this incident we immediately implemented comprehensive measures and are now confident that the necessary systems are in place to significantly reduce risk of this happening again."
Assistant Deputy Coroner Donald Coutts-Wood recorded a narrative verdict that Mr Gregory took his own life.
What do you think?
Post your comments below.
Click here to email the Editor.
Send us a text message. Text STARTEXT followed by a space, your name and postcode and your comments up to a maximum of 160 characters and send to 84070. Texts cost 25p plus standard network charge.