A DEVASTATED husband whose wife committed suicide vowed today to sue the mental health trust which treated her after a coroner criticised it for “astonishing” failures in her care.

A DEVASTATED husband whose wife committed suicide vowed today to sue the mental health trust which treated her after a coroner criticised it for “astonishing” failures in her care.

Alan Hammond said he will issue a writ for clinical negligence against Suffolk Mental Health Partnership NHS Trust after his wife, Sheila, shot herself in the stomach at their home in Spring Lane, Wickham Market.

Coroner Peter Dean criticised the trust's treatment of Mrs Hammond, a mother-of-two who suffered from depression as well as Non-Hodgkins Lymphoma and ME, but did not find it had been negligent.

Mrs Hammond, 51, shot herself two days after she left St Clement's Hospital on September 1, 2005. There was confusion over her discharge and over the purpose of a hospital meeting to discuss her care after which she was allowed to go home. It was not clear what decisions were made and her care co-ordinator was not present.

Dr Dean said: “The care did not meet the basic standards required. There seems to have been a lack of structure that seems to be quite worrying. It is astonishing that the discharge could have taken place in this way.”

However Dr Dean said the evidence did not allow him to link the trust's failings to Mrs Hammond's death.

The trust held an investigation and introduced a series of major changes to reduce the chance of someone dying in the same way.

Mrs Hammond was found dead by her husband on September 3. She had self-harmed before, Suffolk Coroner's District Court heard on Wednesday

At the inquest psychiatric nurse Lynne Andrews admitted that paperwork which was meant to be signed by Mrs Hammond had not been. “My paperwork is not always up to scratch,” the nurse said.

To commit suicide Mrs Hammond used a gun kept locked in a cupboard at home. Her family was unaware she knew where the key was kept. The trust was unaware of the gun's existence.

Mr Hammond told the inquest: “I find it hard to believe that my wife was sent home considering she was still having suicidal thoughts.”

Now the trust has agreed to put the care co-ordinator of mental health patients in charge of care meetings in future, invested in training for care co-ordinator and appointed a care training manager.

They have also introduced a system in which all patients will be discussed in community teams.

He said he would take the trust to court next year but may issue a writ before Christmas.

Mark Halladay, chief executive at Suffolk Mental Health Partnership NHS Trust, said: “I would like to extend the trust's condolences to Mrs Hammond's family and friends, both for their loss and for the pain they have been experiencing since her passing.

“We carried out an internal investigation at the time of Mrs Hammond's death and examined what we could learn from the events at the time. Over the two years since then, we have made a series of significant changes.”

The coroner recorder a verdict of suicide and said he would write to the trust.

AFTER the inquest Mr Hammond paid a moving tribute to his wife, who worked in the NHS as a community nurse before training as a school nurse.

“Sheila was known to hundreds of children and their parents, throughout north and east Suffolk, and was held in high regard for her attention to care and enhanced pastoral activities to support and encourage youngsters across the whole school spectrum of age groups.”

Outside work Mrs Hammond enjoyed sea kayaking, clay pigeon shooting and her garden, a source of pleasure not just to her but to the many visitors she welcomed to the family campsite at Wickham Market with her husband Alan.

“Sheila was very close to her children, Emma, now 22, and Stuart, now 20, and joined them in many activities, ranging from off-road cycling to hill walking.

“Her death was all the more sad simply because the very organisation to which she dedicated so much of her working life let her down at the very time she needed it most.”

A MENTAL health boss today said changes had been made in the wake of Sheila Hammond's death and defended the level of care for high risk patients.

Robert Bolas, deputy chief executive and director of nursing at the Suffolk Mental Health Partnership Trust, said an investigation was made into every suicide where the patient was in contact with the trust and the findings shared with relatives and staff.

Since several high profile suicides where there were fears the patients may have been released from care too quickly, changes have been made to treatment of patients at risk of suicide, Mr Bolas said.

“We have improved our discharge planning standards, looking at if we are planning properly for people to be discharged from in-patient areas.

“We have improved communication with community teams, ensured the family is fully involved in what's needed when the patient gets home, and made sure the right number of follow-up visits are done, based on an assessment of risk.”

Mr Bolas said 25per cent of suicides in Suffolk were people who were in contact with the mental health trust.

In 2004 there were 17 cases, in 2005 there were 17, in 2006 there were 13 and so far this year 17 have been reported.

He said high risk groups included men under 35 years, people who have been discharged from inpatient care within four weeks, people with a history of self harming, people with alcohol and drug problems, people with physical illnesses as well as mental illnesses, those going through bereavement and divorce and those from families with a history of suicides.

Extracts from letter by coroner Dr Peter Dean to Mark Halladay, chief executive of Suffolk Mental Health Partnership NHS Trust and copied to the Department of Health:

“[I wish to draw attention] to the numerous and very significant areas of concern about the care provided to Mrs Hammond in the period of time before her very sad death… I write in the hope that attention to these matters may prevent similar tragedies happening in future…

“[The] lack of communication with family carers, in respect of previous leave periods as well as the final discharge, was an area of great concern to the family and the court, and you will, no doubt, be aware that this is not the first inquest I have conducted into the very sad death of a psychiatric patient where there was clearly a need to involve and listen to the family which was not acted upon.

“The level of communication appears to have been so poor that those who did attend had different views on whether they were to be attending a discharge meeting or a leave planning meeting and, astonishingly, the person who believed she was going to be attending a leave planning meeting also left believing that she had attended one, the outcome of which was a plan for weekend leave, rather [than] the discharge which was actually decided.”

A MOTHER whose daughter lost her battle against paranoid schizophrenia today called for more funding in Suffolk's mental health system.

Jean Fryer's daughter Karen fell to her death from a Woodbridge railway bridge in June. She had been unable to overcome her demons and an inquest later heard she had suffered from increased mood swings in the weeks leading up to her death.

The death of the 34-year-old from Orwell Court, Woodbridge, followed an eight-year struggle to deal with her mental health condition, and had led her family to pay for private treatment for her because they were unhappy with the treatment provided by the public system.

Today Mrs Fryer, 61, of Woodbridge Road, Debach, said the mental health system needed more investment so that people could be treated as individuals. She said there was a “lack of resources in the mental health service”.

“My daughter didn't get the treatment which I think she should have done,” she said.

“Until they can put more money into mental health then this will continue to happen because there simply aren't enough resources to go around.

“People are falling through the net.

“I think that cuts have been made in elderly health and in mental health. The resources are being put where people can shout the loudest.”