Two NHS Trusts that accepted liability for the preventable death of Jack Farrington have responded to the Regulation 28 Prevention of Future Deaths Report, outlining changes that they have since made to improve patient safety.
Solent NHS Trust and Portsmouth Hospitals NHS Trust have accepted full liability for the preventable death of Jack Farrington, a 26-year-old man who took his own life while detained under section 2 of the Mental Health Act in January 2020.
Trust Failings and Areas for improvement
The Trusts’ failings were found to have contributed to Jack’s ability to abscond from the hospital. Key areas requiring improvement include:
- Assessment and recording of patient information
- Information sharing
- Accountability
- Implementation of measures to ensure patient safety
Actions taken by the NHS Trusts
Portsmouth Hospitals NHS Trust’s response
Portsmouth Hospitals NHS Trust stated that it is developing a new system to provide the Emergency Department team with more comprehensive information about patients’ needs and risks before their arrival.
Solent NHS Trust’s response
Solent NHS Trust announced that it is transitioning from paper-based forms to an electronic system integrated with the existing online platform, improving the accuracy and accessibility of patient information.
National NHS response
Professor Sir Stephen Powis, National Medical Director of NHS England, highlighted that Summary Care Records now include details of long-term conditions, significant medical history, and specific communication needs by default, unless a patient has opted out.
Jack Farrington’s story
Jack Farrington, who lived with bipolar disorder and schizophrenia, tragically died after absconding from Queen Alexandra Hospital in Portsmouth. He fell from a bridge over the A3 London Road in January 2020.
Legal action and family’s response
Jack’s parents, Joseph and Catherine Farrington, pursued a civil action against both Trusts with the support of Tees Law. The legal claim concluded in January 2024.
Chantae Clark, from Tees Law, commented on the significance of the case:
“This case underscores the pressing need for improvements in mental health care and highlights the importance of robust oversight and accountability across the NHS and mental health services.”
Findings from the inquest
An Inquest concluded that Jack was not capable of forming an intention to end his life. When he was lucid, he showed a desire to recover and sought medical assistance.
Timeline of events leading to Jack’s death
- 30 December 2019: Jack called 999 during a psychotic episode and was voluntarily admitted to Queen Alexandra Hospital (QAH).
- Initial Risk Assessment: Jack received a ‘Mental Disturbance Primary Survey’ with a risk score of 8, the highest level, requiring Level 5 (black) supervision.
- First Absconding Incident: While waiting for further assessments, Jack absconded through an emergency exit.
- Second Absconding Incident: After being returned to the hospital by the Police, Jack absconded again the following day.
- Detainment and Transfer: Jack was sectioned under Section 2 of the Mental Health Act and transferred to the Hawthorn Ward under Solent NHS Trust.
- Insufficient Risk Consideration: Despite his history of absconding, his risk was not properly addressed by the Hawthorn Ward.
- Seizure and Return to QAH: On 2 January 2020, Jack suffered a seizure and was returned to QAH, where he was placed in the Emergency Department’s “Pitstop” area.
- Final Absconding Incident: Jack absconded once again and tragically took his own life.
Coroner’s prevention of future deaths report
The Coroner issued a Prevention of Future Deaths Report, warning of the risk of future deaths without appropriate action. Key concerns included:
- Inadequate handovers
- Poor record keeping
The Report was directed to Solent NHS Trust, Portsmouth Hospitals NHS Trust, and NHS England.
Conclusion
Chantae Clark of Tees Law emphasised the importance of the legal process in driving change:
“Whilst the Inquest process and pursuing legal action cannot undo the pain caused by Jack’s tragic death, I hope that the conclusion of this case, coupled with the Coroner’s Prevention of Future Deaths Report, serves as a catalyst for change.”
Jack’s family, supported by Tees Law, remain committed to ensuring that lessons are learned to prevent similar tragedies in the future.
