On 28 April 2015, the West London Coroner’s Court heard how 44-year-old Rory Magill took his own life after the nurse who was supposed to be observing him whilst he was in hospital went on a break, leaving him unsupervised, despite him being deemed to be at risk of committing suicide.
Mr Magill, who had suffered from mental health problems in the months prior to his death on 13 June 2013, was admitted to Hillingdon Hospital, having swallowed antifreeze in an attempt at taking his own life on 12 June 2013.
Upon his arrival staff at Hillingdon Hospital recommended that Mr Magill drink vodka and strong beer in order to prevent the antifreeze from seriously harming his kidneys and liver. The hospital did not have the correct antidote for this type of poisoning available and this was considered to be the only viable alternative.
Mr Magill was assessed to have presented a medium to high suicide and self-harm risk and nurses were instructed that he should remain on one to one observation whilst he was recovering in hospital.
In the early hours of 13 June, a nurse responsible for observing Mr Magill went on a break without handing over to a colleague. An unobserved Mr Magill wandered around the ward.
After a visit to the bathroom he approached a member of staff with a broken bathroom call bell cord. This was not confiscated from him. He also informed a staff member that he was having “lots of thoughts”. He was invited to sit in the day room, where he remained unsupervised, before returning to his bedroom. He was later found hanged in the day room and was pronounced dead at 6.40am.
Prior to the inquest, a Serious Incident Report was prepared by the Central and North West London NHS Trust. It was concluded that there were a number of failings in Mr Magill’s care including:
- No early psychiatric assessment while in A&E
- No oral alcohol in A&E
- No alternative antidote for antifreeze poisoning (Fornepizole) held in the Trust
- No request for a follow-up assessment by acute psychiatry in relation to Mr Magill’s behaviour on the ward
- Inadequate implementation of one-to-one observations according to Trust policy
- Inadequate observation of Mr Magill while one of the nurses was on her break
- Inadequate training for registered general nurses and health care assistants in relation to patients with suicidal thought or intent
- Inadequate documentation in relation to quantifying the level of observation needed
- Miscommunication between staff in relation to specialising (one-to-one observation) responsibilities on shift
When recording his narrative verdict, HM Senior Coroner Chinyere Inyama stated that it was in his “clear view that observations at some point amounted to intermittent rather than one-to-one close observations within eye-sight or touching distance”. He added that there had been a “failure” on the part of those responsible for Mr Magill’s care and concluded that “Mr Magill took his own life, in part because the risk of him doing so was not adequately monitored”.
In a statement following the inquest, Mr Magill’s wife Anita said the following of her late husband and the level of care he had received: “Rory was completely let down by those who were supposed to be keeping him safe and I am still trying to come to terms with what has happened. As a family we have lost a loving husband and father because of inadequate care, policies and procedures which jeopardise the safety of vulnerable people.”
The Trust later offered their condolences to Mr Magill’s family.
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