Coroner criticises Sheffield NHS trust after man's suicide

Gareth Etchells-Height died in April 2022

A coroner has criticised an NHS trust over concerns about a man's discharge from a mental health unit after he took his own life.

Gareth Etchells-Height, 42, was found dead at the Wainwright Centre in Sheffield on 24 April 2022.

Sheffield Health and Social Care Trust NHS Foundation Trust has been told to address key issues relating to his care.

The trust said it welcomed "every opportunity" to improve and learn.

An inquest at Sheffield's Medico-Legal Centre in October heard Mr Etchells-Height, who had Asperger's syndrome, had a history of mental health problems.

In February 2022, after presenting with symptoms of psychosis including delusional and persecutory thoughts, he was admitted to Maple Ward in Sheffield.

He stayed at the acute mental health inpatient ward until 22 March before being discharged into the care of Wainwright Crescent, a "step-down" support service which is now called Beech.

The inquest heard Mr Etchells-Height became distressed about his impending discharge from Wainwright Centre on 25 April and was not told he could stay for longer.

Assistant coroner Alexandra Pountney said this "more than minimally contributed" to Mr Etchells-Height's death on 24 April.

'Wholesale inconsistency'

In a prevention of future deaths report dated 20 November, Ms Pountney highlighted a number of concerns.

She said the discharge note to Wainwright Centre had not included Mr Etchells-Height's diagnosis and had also failed to highlight high-risk behaviours or triggers.

She described the note as "not fit for purpose".

Ms Pountney also expressed concerns about patient discharge and safety netting and said there had been "wholesale inconsistency" in healthcare professionals reviewing medical notes.

She further noted there had been a failure to update Mr Etchells-Height's risk assessment, making it "redundant".

"There was a failure generally to keep proper records," she said.

"It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth."

Sheffield Health and Social Care Trust has until 15 January to outline what actions it will take to address these concerns.

When approached for comment, the trust referred to its previous statement issued following Mr Etchells-Height's inquest.

"We are deeply saddened by the death of Gareth," it said.

"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."

Solicitor Martha O'Toole, on behalf of Mr Etchells-Height's family, said they welcomed the coroner's report which had "highlighted several shortcomings".

Ms O'Toole added: "The family are grateful that the coroner has utilised her powers to mandate change which we hope will prevent deaths in similar circumstances in the future."

If you have been affected by any of the issues in this story, the BBC Action Line has links to organisations which can offer support and advice.