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Bury St Edmunds: Inquest hears ‘significant’ changes have been made following teenager’s death at Wedgewood Unit

16:52 15 January 2014

Joe Ruler

Joe Ruler


The mother of a teenager who committed suicide at a mental health unit feels “disappointed” risks were known, but hoped changes sparked by his death would prevent similar tragedies.


Joe Ruler, 19, died at the Southgate Ward of the Wedgewood Unit in Bury St Edmunds, run by Norfolk and Suffolk Foundation Trust, at about 4.50pm on August 29, 2010.

Today’s inquest into his death heard he was found by staff hanging from a bathroom door using bed linen which had been tied to a door handle.

The ligature risks of the ensuite doors had been known several years before Mr Ruler’s suicide.

The tragedy sparked internal and external reviews, with “significant” changes made, including anti-ligature door handles fitted across the trust’s accommodation estate.

The inquest also heard Mr Ruler’s death had been a catalyst for broader improvements around the way the whole system is managed.

Medics had felt Mr Ruler had suffered from some kind of “personality disorder” - rather than a formal mental illness - and the inquest heard improvements had also been made around how to support people with these difficult conditions.

Following the inquest, which was held in Bury St Edmunds, Mr Ruler’s mother Dawn Brazier said: “I have found the evidence that I have heard today incredibly difficult to hear.

“Whilst I am disappointed that risks were known, but not acted upon I feel reassured that Joe’s death had sparked operational and systemic changes which I hope will prevent similar tragedies from occurring in the future.”

Deborah White, director of operations for the Norfolk & Suffolk NHS Foundation Trust, said: “Our first thoughts are with the loved ones of Joe Ruler and everyone affected by this tragedy, including Mr Ruler’s family.

“We welcome this inquest and hope it goes some way to answering questions and giving reassurances of the action we have taken since Mr Ruler’s tragic death.

“I fully accept the coroner’s verdict, the findings of our own internal investigation and the external independent investigation.

“We have already implemented every single one of the reports’ recommendations and all have now been completed.

“The coroner has acknowledged the commitment of our senior management to continue improvements and I will ensure the lessons of this tragedy are never forgotten.”

Coroner Dr Peter Dean recorded a verdict that Mr Ruler took his own life.


1 comment

  • I appreciate that there must have been extensive enquiries but why does it take three and a half years before his inquest took place?

    Report this comment

    The original Victor Meldrew

    Wednesday, January 15, 2014

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