Sheffield patient took his own life over discharge concerns

Gareth Etchells-Height died in April 2022

A patient who took his own life over concerns about his discharge from a mental health unit should have been told he could stay, a coroner has said.

Gareth Etchells-Height, who was 42 and had Asperger's syndrome, was found dead at the Wainwright Centre in Sheffield on 24 April 2022.

An inquest in Sheffield heard he was "distressed" about being sent home.

A coroner concluded that failure to communicate an extension to his stay contributed to his death.

The inquest at Sheffield's Medico-Legal Centre was told Mr Etchells-Height had a history of mental health problems.

Assistant Coroner Alexandra Pountney heard how following an incident at Sheffield's train station, Mr Etchells-Height was taken to Northern General Hospital's Longley Centre on 18 February 2022.

Medical professionals noted he presented with symptoms of psychosis including delusional and persecutory thoughts but was not admitted to an acute mental health unit that day.

Instead, he was admitted to Maple Ward in Sheffield the following day after it was found he had deteriorated.

The coroner said she found it difficult to differentiate between Mr Etchells-Height's presentation on those days and did not understand why admission had been delayed.

Ms Pountney said there had been a missed opportunity to have him assessed by a psychologist, but found the care provided at Maple Ward had been "appropriate and adequate".

On 22 March, when his symptoms stabilised, Mr Etchells-Height was discharged into the care of Wainwright Crescent.

Now called Beech, it provides "step-down" support for those discharged from Sheffield Health and Social Care inpatient wards.

'Poor clinical judgement'

Ms Pountney found the handover notes from Maple Ward had not provided a clear picture of Mr Etchells-Height's mental health and did not include the diagnosis of non-organic psychosis.

She said staff at Wainwright Crescent, who are not clinically trained, had not been told about high-risk behaviours or the importance of medication compliance.

While she found the care provided had been appropriate, there had been "a plethora of missed opportunities" by the early interventions team.

She said this included failure to assess Mr Etchells-Height face-to-face, with assessments instead taking place over the phone.

Ms Pountney also noted Mr Etchells-Height had been distressed over his impending discharge on 25 April.

She said staff should have informed him he would be able to stay for another week, telling the court that failure to do so "more than minimally contributed to his death".

However, she said failings identified were not neglect but rather "poor clinical judgement".

Recording a narrative conclusion, she said Mr Etchells-Height had intended to take his own life, adding: "There were various missed opportunities during his care and his death was contributed to by a missed opportunity to communicate that he would not be discharged on 25 April 2022."

Paying tribute following the inquest, his family said Mr Etchells-Height had been "incredibly special".

'Intelligent and capable'

They said: "He was an interesting person and had his special interests, which included buses, and could tell you anything about a certain bus, including its number, fleet, where its garage was situated and the type of engine it had.

"Notwithstanding Gareth's neurodiversity, he worked in various jobs and was an intelligent and capable individual."

A spokesperson for Sheffield Health and Social Care Trust said: "We are deeply saddened by the death of Gareth. We always strive to give the best care possible to our service users and we welcome every opportunity to learn and improve the way we do things."

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