Hospital failed man who fell to his death - coroner

Windows at Southend Hospital where Aaron Deeley took his own life in 2022 were known to have defects

Action must be taken at a hospital where a suicidal man fell to his death, a coroner has warned.

Aaron Deeley, 43, died in January 2022 after falling from a second-floor window, which was known to be faulty, at Southend University Hospital.

Mr Deeley had several known suicide attempts and was meant to be under one-to-one observation, however this was removed hours before his death.

Mid and South Essex NHS Foundation Trust (MSE) admitted failings in his care during an inquest in May and said action had been taken.

'Care and safeguarding failings'

In a prevention of future deaths report, Essex coroner Sonia Hayes said there had been "failings in the care and safeguarding" by the trust which contributed to Mr Deeley being able to take his own life.

Mr Deeley was an inpatient in Southend's acute medical ward and awaiting an assessment by the Mental Health Liaison team from Essex Partnership University Trust (EPUT).

A jury concluded in May that there had been several issues in Mr Deeley's care.

It noted there had been inconsistencies in completing the medical ward's enhanced observation form on the day before his death.

Also, after a previous suicide attempt in December 2021, there was insufficient detail from Southend Hospital in his discharge letter.

The discharge paperwork from the mental health team was sent to the wrong GP address.

Confusing policy

The coroner highlighted there had been confusion from the medical trust about what was required to ensure a patient waiting on a Mental Health Act assessment could be put under one-to-one observation.

She said Mid and South Essex Trust's policy on the issue was "confusing".

Ms Hayes said: "There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety."

Matthew Hopkins, chief executive of Mid and South Essex NHS Foundation Trust said a full investigation took place following Mr Deeley's death.

He said: "We have improved our policies and procedures to ensure the safe supervision of mental health patients on our wards. Immediate action was taken to secure the windows and appropriate action has been taken to ensure that our windows are safe for all patients.”

Paul Scott, CEO of EPUT, said the trust would look at the coroner's recommendations and was "committed to ensuring patients receive the right care at the right time".

He said the trust's mental health liaison teams worked closely to ensure patients "receive the most appropriate mental health support to meet their individual needs".