A SERIES of failures were made by staff at a mental health unit a jury ruled at the inquest of a suicidal police sergeant who killed himself the day after being admitted.
Sgt Richard Bexhell, a father of four, was found hanging by his belt attached to an air vent less than 24 hours after being admitted to the Woodlands Unit in The Ridge, Hastings.
It was the third inquest into three deaths at the unit during 2008 and 2009.
A jury inquest of Susannah Anley, 34, returned a verdict of death by misadventure contributed to by neglect. She died the day after she had been admitted after suffocating herself with a bin liner.
A jury inquest of John Blair returned a verdict of suicide after he hanged himself two days after being admitted.
After almost three hours of deliberation at Eastbourne Town Hall on Friday (March 2) the jury returned a verdict that the 49-year-old committed suicide.
The jury foreman made the following observations under the Coroner’s Rules: “On admission there was no risk assessement or separate care plan made.
“Referral papers were not read by both admitting parties. Regular ligature point inspections had not identified the extraction unit as a risk.
“The observation section of the multi-disciplinary assessment form was not clear.”
The foreman also went on to say the 15 minute observation watch which staff were carrying out was appropriate.
She continued: “An appropriate level of risk was chosen and correct level of observation maintained.”
During the four day hearing the jury had heard how Sgt Bexhell’s mental state of health rapidly deteriorated following the death of a close friend in June 2009 and an incident involving two youths fighting which he did not report.
He feared he would go to prison because “he had done something wrong.”
After trying to strangle himself with a towel during a family holiday in August 2009, his father and brother Chris took him to the Conquest Hospital where he was sectioned under the Mental Health Act.
But by 2pm the following day he was found hanging in his room and was pronounced dead at 4.11pm in the Conquest Hospital on Sunday August 30.
The inquest heard how psychiatrist Dr Abdul Dar had failed to complete a risk assessment on Sgt Bexhell or read the notes of a nurse prior to his admission.
East Sussex Coroner Alan Craze said: “This has been a complete tragedy, a devastating a shocking tragedy.”
A statement issued by the solicitor representing the family Paul Sankey read: “Richard and his family trusted staff at the Woodlands Unit to care for him at time when he was vulnerable. They feel the unit let him down. Admission processes were not properly followed.
“No risk assessment or care plan was prepared at the outset and there appears to have been confusion between staff as to how often he should have been observed. “One of the worse features of what happened is that there has been a succession of deaths at the unit.
“If lessons have been learned they have been learned too slowly.”
In another statement issued via Mr Sankey, Sgt Bexhell’s wife Lyn paid tribute to her husband, saying: “Richard was a brilliant and loving husband and father. “He was the sort of person who would do anything for anybody and would always go the extra mile to help people out.
“Since his death we have received countless letters from people whose lives he touched, saying what a special person he was.
“He was dedicated to the police service and gave 22 years of loyal service to Sussex Police; he was delighted when he was promoted to Sergeant last year.
“We miss him desperately, but we are grateful for the Coroner’s investigation which has highlighted shortcomings at the Unit. Nothing can bring Richard back. We only hope that changes in practice at Woodlands will prevent the same happening to others.”
Helen Greatorex, executive director of Nursing and Quality for Sussex Partnership NHS Foundation Trust, said: ‘We were deeply saddened by Mr Bexhell’s tragic death. We continue to extend our sympathy to his family and friends.
“While nothing will bring these people back, we owe it to their memory and to their families to learn from what happened and continually improve.
“Richard Bexhell died in August 2009. Since then there have been many changes to our hospital at Woodlands. We reopened the hospital in July 2010 with new leadership and new ways of working. It is now a beacon of good mental health practice in Sussex and beyond.”
The statement from the partnership added that it will be reviewing the evidence and findings presented at the inquest to ensure that any further lessons are learned.