Action should be taken to prevent future deaths after a man in his 50s was hit by a lorry shortly after leaving a mental health hospital, a coroner has said.
Andrew Gibbins, a voluntary patient at the Wedgwood House facility on the West Suffolk Hospital site, deliberately walked out in front of a heavy goods vehicle on the A14 on January 15, 2020.
An inquest in December heard Mr Gibbins, who had tried to step out in front of vehicles twice previously, had been escorted to West Suffolk Hospital’s acute assessment unit for tests that evening.
The 54-year-old, found looking “lost and confused” during a cigarette break, was escorted back to the hospital by a security guard – and during the trip, told him he was feeling suicidal.
But this information, although communicated by the security guard, did not reach relevant medics at either facility.
Area coroner Jacqueline Devonish said this could have been a “missed opportunity” to support the 54-year-old and NHS bosses said a serious incident review drawn up by both the Norfolk and Suffolk Foundation Trust (NSFT) and West Suffolk Hospital led to “numerous” changes in procedure.
Ms Devonish has since drawn up a report to prevent future deaths which calls on both NHS trusts to take action.
Health bosses must reply to the report by February 18, 2021, spelling out changes they have made or intend to make to prevent further tragedies.
A meeting reviewing the response to the incident is understood to be taking place later in January.
Following the inquest, NSFT chief nurse Diane Hull said: “Our hearts go out to Mr Gibbins’ family and we are keen to support them in any way we can.
“(Both trusts) looked together at the care given to Mr Gibbins, and as a result have taken measures to ensure teams work more closely with each other in the future.”
Mr Gibbins’ mother and sister, Jean and Julie, said their loss had been “extremely hard to bear”, but they were relieved recommendations had been made to “close loopholes in the system”.
They added: “We have always believed that Andrew’s tragic death could have been avoided if greater care was taken to supervise, reassure and stay with him during and after his visit for tests.”
A West Suffolk Hospital spokesman said: “These were tragic circumstances and we again offer our condolences to Mr Gibbins' family. We are carefully considering the coroner's findings and we continue to work with NSFT to review and improve our handover processes.
"We are also updating our mental health policy and risk assessments, taking into account the coroner's concerns."
Mr Gibbins’ medical cause of death was recorded as multiple injuries as a result of the road traffic collision, with the coroner concluding he died by suicide.
- For confidential support call Samaritans on 116 123, visit a Samaritans branch or visit their website.
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