Changes called for following suicide verdict at inquest

The coroner's inquest into the death of Matthew Arkle, 37, who died in April 2017 whilst at Wedgwood House in Bury St Edmunds, has recorded a verdict of suicide.

Matthew was admitted to Wedgwood House mental health unit in Bury St Edmunds, which is run by Norfolk & Suffolk NHS Foundation Trust, in February 2017, following an overdose. It was reported that his auditory hallucinations had worsened, particularly at night, and he was smoking more, which in turn impacted on the effectiveness of his medication. 

In early April, his care co-ordinator expressed concerns about his depressed mood, which his family had witnessed as well and they were sufficiently worried that they requested the hospital not to grant him unsupervised leave, as they were visiting London for the day on April 4th and they didn’t want Matthew, who could be forgetful, to feel abandoned, as they usually visited him every day. 

On April 4th Matthew requested, and was allowed, an hour’s unescorted leave in the evening, despite the family’s request. The inquest heard that the discharging nurse was not aware of the family’s request or the concerns expressed by his care co-ordinator the day before but assessed Matthew as suitable to be granted such leave.

By late evening, he hadn’t returned, and the police were alerted. They contacted his mother who was at this time unaware that he had gone missing from hospital. The following day, the police increased Matthew’s missing person risk level from medium to high. 

On Thursday morning, the special search unit, assisted by search and rescue volunteers, found Matthew’s body within Wedgwood House’s grounds near the car park. 

Tim Deeming, a Partner at Tees, helps families to cope with the inquest process. He said that Matthew’s family felt there were several questions which remain unanswered: 

“The Court heard that there were repeated basic failures at the Hospital including fundamental issues such as record-keeping and key individuals not knowing of the family’s wishes not to give Matty unsupervised leave. In addition, his fantastically dedicated care worker – who had known Matty for years – had the day before highlighted that it was the lowest that she had seen him for a long time. 

“Had such information been available and had the family been contacted earlier by the Trust when Matty disappeared, which it is accepted that they should have done, the Police and search teams could have been actively working sooner to locate him. These failures meant there were missed opportunities to possibly help prevent this tragic incident. The Police have confirmed that they would have treated Matty as a high risk missing person and drafted in support for the search.”

Speaking after the verdict, Matthew’s mother, Sheila, said:

“We thought Matty was safe because he was in hospital. He was let down by the people who were meant to be looking after him. Nothing can bring Matty back, but if just one family could be spared of going through what we’ve gone through then there is a legacy for Matty…”

Tim Deeming said: “This is not the first incident to have occurred at the Hospital Trust, and it must be devastating for families who have gone through a similar experience to hear of such repeated concerns. 

Given the evidence that has been heard and the jury’s findings it is heartening to hear that the Coroner will be submitting a Prevention of Future Deaths report so that effective lessons are learnt as widely as possible and similar circumstances avoided, taking into account the highlighted failures identified by the jury which were:

• Failure of appropriate record keeping
• Failure of verbal and written communication
• The general high level of activity and stress on the ward
• The delay in noticing, reacting to and reporting Matthew as missing
• The timing of Matthew’s release, being the late afternoon.

Please note: the family has specifically requested not to be contacted by the media and have asked that any enquiries should be directed to Tim Deeming at Tees Law: tim.deeming@teeslaw.com

Free, confidential advice on medical negligence

Call for a FREE initial consultation on 0800 013 1165

Alternatively, come in for a free, confidential, no obligation chat, or fill out our enquiry form and we will let you know how we can help. We can also visit you at your home if you wish.

Our medical negligence lawyers are based in:

• Cambridgeshire: Cambridge
• Essex: Brentwood, Chelmsford and Saffron Walden
• Hertfordshire: Bishop's Stortford & Royston

But we can help you wherever you are in England and Wales.