The 4 day inquest into the death of Dean Taylor concluded earlier this year in April 2022. However today (5 September 2022) the family received a formal letter of apology from the Trust who were responsible for Dean’s care at the time of his death.
Background
Dean was a very caring and loving brother, uncle and son. When he was 18 years old his mental health deteriorated significantly and he was eventually diagnosed with paranoid schizophrenia. Tragically, from this point in time he was unable to live an independent life with admissions to hospital and supported accommodation for the duration of his life.
In 2018 Dean’s mental health took a turn for the worse after being forced to move from the accommodation that he had lived in for a long period of time due to a change in its criteria. He soon became non-compliant with his medication and his family raised their concerns with his community team about his deterioration.
In May 2018 he was admitted informally as a patient on the Priestley Unit in Dewsbury and District Hospital. He remained there until 2 July 2018 at which point he was discharged back to his supported accommodation. During this admission he absconded 14 times from the ward, 8 of those involved him climbing onto the roof from the garden.
Final Admission
Dean’s final admission was following him being sectioned under the Mental Health Act after he climbed into the ward stating he needed an admission. At first he was transferred to a private hospital in Darlington but following him absconding on 18 August he was transferred back to the Priestly Unit on 29 August.
Following his transfer he began to abscond again via the same method as his admission between May- July.
On 10 October he was due to be transferred to a PICU due to his high risk of absconding when he made his way into the garden where he then proceeded to abscond by climbing up on the roof. He tragically went on to take his own life by jumping from a nearby railway bridge.
The Inquest
The Inquest took place on 4 April 2022 lasting four days before a jury. Evidence was heard from a number of witnesses about Dean’s care and treatment whilst at the Priestley Unit. The Inquest heard that a Serious Incident Report completed by the Trust found that prior to Dean’s death the Trust were already aware of the fact the other patients were able to climb onto the roof and abscond but steps identified to prevent a recurrence where not put in place until after Dean’s death.
Conclusion
The Jury after hearing the totality of the evidence found that Dean’s risk of absconding from the ward during his admission was not managed effectively due to complacency towards Dean’s absconding, the ineffective security in the courtyard and the risk reporting system not picking up on this.
They also found that it was foreseeable the day before his death that Dean would abscond due to the multiple previous absconsions and that he was at higher risk of absconding due to a recent incident on the 8 October and being told by his Psychiatrist that he was liable for PICU.
They concluded that although his death was not foreseeable it would have been prevented on the 10 October if the additional security measures had been in place.
Summary
This is a sad case where Dean’s death could clearly have been prevented had essential works recommended many months before his death been carried out by the Trust to ensure that patients could not abscond from the ward. The family were pleased to see that following his death those changes were made immediately but were saddened that it took his death for that to happen. They welcomed the apology that has come from the Trust today.