Inquest solicitors case study

Posted by Gemma Osgood on

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We were instructed by Mrs M, acting as personal representative on behalf the estate of her late son, S, aged 29. The Defendant was Solent NHS Trust, the body in control of St James's Hospital.  

On or around January 2013 S came back to the Portsmouth area from Norfolk.  He was placed in a shared bedsit by a community group.  According to the evidence given by his mother at the inquest hearing, although S was depressed and unhappy, he wanted to get better and wanted some help to sort his life out.  He had got a flat sorted out and had sorted out his benefit entitlement.

He had a history of drinking heavily and self harm. He was taken to Queen Alexandra Hospital on 20 January 2013 after self harming and drinking heavily. He had expressed suicidal intentions. The following day he was admitted to Hawthorns Ward, The Orchards, as a voluntary patient. 

The plan was to monitor on level 2, for 15 minutely observations until MDT review.

On 22 January 2013 S left the ward without explanation. He went to his local GP who contacted Hawthorns expressing concern S who said he was planning to hang himself. It was agreed he would return to Hawthorns that evening, which he did.

S remained at Hawthorns for the next few days. On 27 January 2013 at 20:00 hours he was noted to be missing from his bed. The police were contacted and S was found by security officers hanging from a tree in the grounds of St James Hospital.  A note was found on his person addressed to his mother. 

Following S's death, a root cause analysis was carried out by the hospital which identified a number of failings in the care provided to its patients.

BL Claims solicitors were approached by Mrs M in July 2013. An inquest was conducted on 21 March 2014 at Portsmouth Guildhall. BL Claims solicitors provided representation for the family. The Coroner concluded his enquiry with a narrative verdict. The Coroner considered that whilst S had been in a severely distressed psychiatric state, it was not clear that he intended to take his own life.  Therefore the Coroner did not make a verdict of death by suicide.  He noted that significant changes had subsequently been made at Orchards and in those circumstances he did not have to write to the hospital formally with recommendations for changes to be implemented.

Following the inquest a Letter of Claim was sent to the Defendant with a Part 36 offer for £12,500. The Defendant accepted this offer immediately.

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About the Author

Gemma is a Senior Associate in our Clinical Negligence team with extensive experience in all areas of medical negligence claims.

Gemma Osgood
Email Gemma
023 8085 7248

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