2 weeks Ago By [email protected] (Gary Porter, Stephen Topping)
An 'amazing' former firefighter who struggled with his mental health died following 'neglect' at a Cheshire hospital. An inquest heard how John Paul Pratt attended the Countess of Chester on September 8 last year following an acute episode of psychosis. But two days later, he left his hospital room unnoticed before ending his own life.
Jurors ruled on a catalogue of failings in how John was treated by the NHS prior to his death. They concluded that the 54-year-old had died by suicide, which was contributed to by 'neglect', Cheshire Live reports . His partner, Janine Carden, said: "John was an amazing person.
One of life's helpers, a much-loved partner and father who attended A&E to seek help. READ MORE: Body found following major Elton Reservoir search as MP issues statement on tragedy "He should have received the help he needed but did not, and this tragically led to his death. His death identifies serious flaws in the care of vulnerable mental health patients who are at risk of self-harm.
" Paul had a history of post-traumatic stress disorder following his career as a firefighter. A five-day jury inquest heard how there were issues with John's care - including failings in risk assessment, communication between teams, and a lack of action on Saturday, September 9 2023 which probably contributed to his death. Countess of Chester Hospital (Image: Getty Images) Both the Countess of Chester Hospital and Cheshire and Wirral Partnership NHS Foundation Trust have fully accepted the coroner's findings and apologised to John's family.
At the hospital emergency department, his mental health was assessed and it was agreed that he required admission to a mental health unit, but there were no available beds. John and his partner waited in a small windowless room off the emergency department for two days. It was accepted at the inquest that the emergency department was not a safe environment.
One to one support was requested but was only in place between 8.30-9.30am on September 9.
This support was removed due to a lack of staffing and the support worker raised concerns to his management and with Psychiatric Liaison Team (PLT) staff from the CWP at the hospital, as he did not feel it was safe to leave John. No assessment of John's risk to himself was undertaken before support was removed, and no plans were put in place to replace that support. A further assessment was undertaken on the same morning.
This assessment failed to correctly identify John's high risk to himself. It confirmed that John did require a mental health bed, however, there was none available and he was told he needed to change GP to be put onto a CWP waiting list. On the Saturday evening, John's mental state deteriorated and he was exhibiting severe suicidal thoughts.
John's partner sought help from an emergency department nurse. She was very concerned about how withdrawn John was and called CWP mental health staff to attend. Although they attended, they failed to conduct any assessment, did not ask John any questions and the evidence showed no plans were put in place to support him.
In the early hours of Sunday, September 10, John's partner had gone home to collect paperwork to change GP, alerting emergency department staff before she left of John's high risk to himself. No checks or observations were made, despite there being a policy in place requiring this, and John left the room unnoticed before taking his own life. His family are extremely concerned that the same failings could be made again by CWP staff.
Help and support Samaritans (116 123) samaritans.org operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at jo@samaritans.
org , write to Freepost SAMARITANS LETTERS (no more information needed) and visit www.samaritans.org/branches to find your nearest branch.
For support for people feeling suicidal, if you are concerned about someone or if you are bereaved by suicide see http://shiningalightonsuicide.org.uk CALM (0800 58 58 58) thecalmzone.
net has a helpline is for men who are down or have hit a wall for any reason, who need to talk or find information and support. They're open 5pm to midnight, 365 days a year. Greater Manchester Bereavement Service Greater Manchester Bereavement Service can help to find support for anyone in Greater Manchester that has been bereaved or affected by a death.
No one needs to feel alone as they deal with their grief. www.greater-manchester-bereavement-service.
org.uk Childline (0800 1111 ) runs a helpline for children and young people in the UK. Calls are free and the number won’t show up on your phone bill.
PAPYRUS (0800 068 41 41) is a voluntary organisation supporting teenagers and young adults who are feeling suicidal. Beat Eating Disorders: Beat provides helplines for adults and young people offering support and information about eating disorders. These helplines are free to call from all phones.
Adult Helpline: 0808 801 0677, Studentline: 0808 801 0811, Youthline: 0808 801 0711. www.beateatingdisorders.
org.uk Anorexia & Bulimia Care: ABC provide on-going care, emotional support and practical guidance for anyone affected by eating disorders, those struggling personally and parents, families and friends. Helpline: 03000 11 12 13.
www.anorexiabulimiacare.org.
uk/ Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts. Bullying UK is a website for both children and adults affected by bullying studentsagainstdepression.org For information and links to charities and organisations that can help with substance abuse, visit https://www.
supportline.org.uk/problems/drugs/ Alice Wood of Farleys Solicitors, who represented the family, said: "No-one in John's position should have been left in the way he was, which is demonstrated by the jury's finding of neglect.
We are grateful for the detailed consideration of the inquest evidence by the Coroner and the jury, which has highlighted that there is a lot of learning required. "It was concerning to see that some of the witnesses didn't seem to grasp the importance of the missed opportunities highlighted to them." NHS chiefs say they are taking action to improve following John's tragic death.
Gary Flockhart, Director of Nursing and Therapies, Cheshire and Wirral Partnership NHS Foundation Trust, said: "First and foremost, we would like to express our deep and sincere condolences to John's family and friends and our thoughts remain with them during this difficult time. We are sorry that the level of care John received did not meet the standards that we expect. "Following John's death, the Trust conducted a joint serious incident investigation with the Countess of Chester Hospital and have actioned improvements to strengthen mental health assessments and joint working within the emergency department.
The Trust accepts the Coroner's findings in full and will further review opportunities for us to learn and improve our services." Sue Pemberton, Director of Nursing and Quality and Deputy Chief Executive Officer at the Countess of Chester Hospital NHS Foundation Trust, added: "We extend our deepest sympathies to Mr Pratt's family for their loss. We fully accept the outcomes of the coroner's inquest and recognise that some aspects of Mr Pratt's care should have been better, and for that we are wholeheartedly sorry.
"The environment of an emergency department is challenging for any patient suffering a mental health episode. We are taking action to improve our services by creating a specially designed waiting area in our emergency department that is more suitable for patients with mental ill health, coupled with additional training for our staff, so that we can better support our patients to keep them safer and more comfortable while they wait for transfer to a specialist mental health care setting.".
