Medical Law Experts Demand Review After Failed Procedures Led To “Avoidable” Suicide
03/02/2011
Medical law experts have demanded an urgent review of procedures at an NHS mental health trust following the suicide of a railway engineer, despite his repeated requests for help in the weeks before his death.
Peter Bane, 47, a senior engineer from Happisburgh, Norfolk, was killed when he was hit by both a passenger train and a freight train on 16 February 2010. A suicide note was found in his pocket and a coroner heard that he had told Norfolk and Waveney Mental Health NHS Foundation Trust that he was contemplating taking his own life on at least three occasions in the two weeks prior to his death.
An inquest into his death, which ruled that Mr Bane had killed himself whilst suffering disturbance of the mind, heard that the procedures in place at the time for referring patients to the mental health centre often led to vital information going unrecorded and that the suicide risk appeared to have been underestimated by staff at the mental health centre.
Now medical law specialists at Irwin Mitchell are calling for an urgent review into the way in which patients referred to psychiatric services are handled, claiming that more could have been done to prevent Mr Bane’s death.
Anita Jewitt, a medical law specialist from Irwin Mitchell representing the family, said: "Peter Bane was a hardworking, professional man who is sorely missed by his family and friends. His family have suffered enormously over the past year and wanted the inquest to provide answers to their questions over the events leading up to his death.
“Peter and his wife Angela did all they could to seek out urgent assistance from the psychiatric services. Peter's GP responded to his pleas for help in the appropriate manner and referred him to mental health professionals. Unfortunately at this stage the loss of vital information has let the family down and is totally unacceptable.
“The evidence given regarding the circumstances of Peter's death was particularly harrowing and the consequences of the errors in this case will live with the family forever and they remain convinced that more could have been done to prevent his death.
“The Coroner has suggested that she will be making written recommendations to the Trust to try and prevent further deaths and we welcome these steps. The family and I hope now that important lessons are learned by this Trust, and others, to improve the referral process from GP to mental health practitioners to prevent the same thing from happening again.
“Patient safety should be the number one concern of health professionals and the signs could not have been clearer that Peter was very worried that he would hurt himself. If the mental health professionals had received all of the information, unfortunately it appears that Peter’s death may have been avoided”.
The inquest also heard how Mr Bane had originally approached his GP on 5 February 2010 and reported very strong urges to commit suicide by walking in front of a train. His GP assessed that he was at a "very high" risk of self harm and arranged for the psychiatric services to undertake an urgent assessment at Mr Bane's home.
This assessment should have occurred within four hours but a home assessment did not take place. Instead, he was telephoned by the psychiatric services, to which Mr Blain explained that he felt unsafe at home and that he wanted to commit suicide by walking in front of a train. He repeatedly requested to be admitted to hospital but his requests were refused and he was advised that he only required a change in his medication.
Peter attended the follow-up appointment on 15 February and was given an increase in his medication, but no further action was taken in relation to a hospital admission.
He went to work on the morning of 16 February but left shortly afterwards. He then walked in front of a train with a suicide note in his pocket.
He leaves a wife and a 12-year-old daughter, as well as two adult children from a previous marriage.
His widow Angela Bane said: “We are devastated by Peter’s death. We knew he wasn’t well and had tried everything we could to seek out help. I feel completely let down and angry. It is obvious that more should have been done to prevent his death. Peter did exactly what he said he would do and the mental health services have failed him.
“Peter had suffered from episodes of depression in the past, but we had battled through those times and he had been successfully treated and held down a very good job in London. There’s no reason why treatment would not have been effective on this occasion too.
“We can only hope that by highlighting our tragic case, lessons can be learnt so that others do not have to go through the same suffering that we have.”
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