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Psychiatric patient was ‘let down by the system' inquest hears
A psychiatric patient found hanged in hospital grounds a week after he went missing, was let down by the system – an inquest in Bradford has heard.
The hearing was told that nurses’ notes charting how 31-year-old Peter Barnes was feeling hopeless, was overheard detailing a plan to kill himself with his shoelaces, was talking about the after-life and wanting to get out of the Cygnet hospital in Wyke where he was being detained under the Mental Health Act, had not been flagged up to the ward manager.
Ward manager Gwen Horn, responsible for safety on the intensive care ward, had earlier told the inquest she had seen an improvement in Mr Barnes who had only been transferred there from another hospital weeks earlier.
But Tom Stoate, representing Mr Barnes’s family, challenged that by reading nurses’ notes made in the days running up to his disappearance on an unsupervised cigarette break, Describing some of those notes as “in part not legible”, he asked her: “As someone responsible for ward safety, when a vulnerable schizophrenic patient talks about life after death, does that give you cause for concern?”
Mrs Horn said it had not been drawn to her attention. “The nurse who made that entry is a registered nurse. He’s the nurse speaking with Peter,” she said.
Mr Stoate continued: “That’s not appropriate for concerns like that not to be raised with you. It seems the system has failed Peter Barnes?”
Mrs Horn replied “Yes.”
She said nurses’ notes would be handed over to on-coming staff at change-over times and there would be discussions, but she was not involved in their decision-making and was not always on the ward because she also had other responsibilities for sales, staff recruitments, salaries and annual leave.
The inquest also heard evidence from Mrs Horn that she was not aware that doctors had raised concerns about staffing levels on Mr Barnes’s ward at the time of his disappearance and that although safety checks were carried out in the hospital to make sure there was nowhere patients could hang themselves, there was nothing to stop patients from getting to the trees in the grounds.
“We don’t risk assess trees, with all respect,” she told the inquest.
Hospital notes recorded Mr Barnes starting his 30-minute unsupervised cigarette break at 1.45pm on October 13, 2011. In her statement, Mrs Horn had said at 2.30pm she was told by one of the nurses that another nursing assistant had searched the grounds.
“That would seem to be a 15-minute search of the hospital grounds,” said Mr Stoat, addressing Mrs Horn.
The inquest has heard that it was a week later before Mr Barnes’s body was found hanged in woodland concealed by trees and shrubbery. A post-mortem examination found undigested food in his stomach, suggesting he had died within a few hours of going missing.
The hearing continues.