GROSS NEGLECT

Nurses at the hospital were under doctor's orders to monitor 59-year-old Ernest Clarke every five minutes, but a staff shortage meant he was left alone for 20 minutes, during which time he hanged himself.

Cheshire coroner, Nicholas Rheinberg, described the circumstances of the hanging, which happened on September 13 last year, as an incident of gross neglect, during a hearing at Crewe Coroner's Court.

The court heard that Mr Clarke, a postman from Handforth Road in Crewe, had become more and more depressed after suffering a back injury while working at Royal Mail in Christmas, 1999.

Mr Clarke's wife, Ann, told the court that in June, after months of pain, Mr Clarke, visited a psychiatric consultant at Leighton Hospital.

Mrs Clarke said: "The hospital did not really keep us updated with his progress and on August 24 he tried to cut his wrist with a razor blade and we were not told about this.

"I was told this had happened by another patient," she added.

Dr Russell Millward, Consultant Psychiatrist at Leighton, treated Mr Clarke: "He was very much a picture of a depressive, he was pessimistic, and the physical problem with the back was certainly an aggravating factor," he told the court.

"I do not believe that cutting his wrists was life threatening, at some stage he made a noose in sight of the supervising nurse which was also of much concern to us."

Dr Millward confirmed that they stepped up his supervision routine into September 2000: "He had been on regular observations throughout, but he was put on more frequent observations towards the end of August."

The court heard how on the day of the hanging, four staff were manning the ward, which was full to capacity with 23 patients, when a change of shift happened at around 3pm.

Ward Manager, Paul Byrom, told the court during the change of shift only two nurses began work with one more being drafted in to cover a late arrival.

When asked if three nurses were enough Mr Byrom admitted it was not a desirable situation but said: "On Wednesday we do not have the ward rounds so we usually get by."

Health Care Assistant, David White, came on duty at around 2pm and he told the court: "I saw him at 3pm when I started the fire check."

According to the ward's observation record Mr Clarke was checked until 3.35pm from which time he was not checked until he was found at 3.55pm.

Mr White added: "It was a difficult shift from the start, it was a bit disjointed from what I remember.

"I was quite concerned when I first took over as there was only two on hand that particular day, and we had a third person come on from another ward."

Mr White said that when Mr Clarke was found he was on the phone trying to get staff in for the night shift: "We were short staffed again, I had been asked to phone up to try and get staff," he said.

"I am not sure where the third person was but it was a very busy shift. At the time there were not enough staff on the ward."

When asked who was responsible for carrying out the checks Mr White answered: "Nobody was designated on that day, I had taken the task on but the last time I saw the file it was with another member of staff and I rightly or wrongly assumed that had been done."

Dr Millward added: "I have to say that often as a consultant judgement is constrained by staffing levels.

He continued: "Invariably there are resource problems in the NHS in my experience.

"If the five minute observations had been adhered to I think it is very unlikely Mr Clarke would have completed the act of hanging.

"I had been concerned as to the observation of this policy in that on different wards it was being operated differently, I indicated my concern to the hospital management in writing.

"The longer the time the greater the negligence and a failure to observe for 20 minutes is most unacceptable," he added.

When asked if this would amount to gross negligence Dr Millward replied: "I would have to say yes."

Mr Rheinberg said: "Mr Clarke was in the care of the hospital and had the five minute checks been carried out Mr Clarke would not have been successful in his attempt.

"In failing to carry out the observations there was gross neglect.

Mr Rheinberg ruled: "I find that he took his own life whilst the balance of his mind was disturbed in circumstances in which neglect was a factor."

Simon Yates, Chief Executive at Leighton Hospital said in a prepared statement: "The Trust has held its own internal inquiry in the circumstances of Mr Clarke's death.

"Following a review of the inquiry's findings we have implemented changes to the Trust's procedures for the supervision of mental health patients."

BY PETE HENSHAW