A "kind and loving" son killed himself on a motorway after multiple, serious failings at a psychiatric hospital, an inquest jury concluded.
Wallasey man Michael Cooke, 30, was an inpatient at Springview Hospital in Bebington, Wirral, when he was allowed out unsupervised into the hospital grounds on August 16, 2019. At around 10.50am that morning, he was hit by a vehicle on the M53.
In the days leading up to his death, Michael had handed a box containing some sweets, beads and a note to a receptionist and asked for it to be passed to a family friend. The receptionist did not give this to any of his clinicians, despite the fact the note revealed his mental health was seriously deteriorating, and it later had to be recovered from clinical waste after his death.
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Michael was detained at Springview under Section 3 of the Mental Health Act in July, 2019, after an assessment found he posed a risk to his own safety. He had previously been diagnosed with Autism Spectrum Disorder (ASD) and Pathological Demand Avoidance (PDA).
Last week, a jury at Liverpool Coroner's Court found that a series of failures by staff at Springview Hospital "more than minimally" contributed to his death. They also concluded he "died by suicide whilst suffering from poor mental health about which he had no insight".
His parents said they believe his death was avoidable and slammed Cheshire and Wirral Partnership NHS Trust (CWP), which runs Springview, for suggesting "nothing could have been different". In a statement issued via their legal team, Broudie Jackson Canter, they said: "We want to thank each of the jurors; their findings bring recognition and accountability for what happened. These failings are things we as Michael’s parents have known all along, but for years the Trust have been making us feel like we were just overprotective parents, and that nothing could have been any different.
"But we know Michael’s death didn’t have to happen. So many times during this long inquest process we asked ourselves if it was even worth it, and now we know that it was.
“Our wish has always been for no other family to go through what we have. It’s not about blame, but when there are systems in place like this that aren’t keeping patients safe, there needs to be a discussion about how we can improve them. We hope by speaking out we can make more people in the community aware of these issues and prevent what happened with Michael happening again."
The jury had heard that the diagnosis of Michael's ASD was incorrectly recorded on the CWP electronic records system, and although a full report on his mental health was available to his clinicians at Springview, they never read it.
On August 8, 2019, two nurses decided that Michael could be granted unaccompanied leave within the hospital’s grounds. Trust policy required a clinical risk assessment to be done in advance of this decision, however, no documentation indicated one was done, as there was no documented risk assessment since his admission. In addition, his care plan was not updated following this change.
In the lead up to his death, he was allowed on unsupervised grounds leave several times. During the morning of August 16, he told staff that he was feeling anxious, but after he was given medication he was allowed on leave in the hospital grounds. Just 15 minutes later he died.
The jury had been told there were no perimeter fences around the general psychiatric unit. The Trust’s policy provided no specific guidance on what kind of risk assessment should take place prior to granting unaccompanied grounds leave, and was "silent" on how to consider the risk of a patient absconding.
After a five day inquest, the jury concluded there had been missed opportunities to prevent Michael's death. In relation to the note he handed in to reception, they wrote: " This was not handed to the ward and is a failure which contributed in more than a minimal way to Michael’s death, the note could have prompted a review with Michael. This was a missed opportunity ."
They also described his care notes as "lacking" and said continued grounds leave was "not appropriate". The failure of his inpatient clinicians to read the full report on his diagnoses was considered a "serious failing".
Michael's description of feeling anxious on the morning of his death was another "missed opportunity", which should have led to a review of his mental state. It was also noted that due to staff shortages no psychologist was available while Michael was an inpatient.
A statement from Broudie Jackson Canter said: "Michael's parents remember him as kind, loving, happy, sincere, loyal, genuine, humble, caring, affectionate, and sentimental.
"They say he was the embodiment of what was good and right in the world. Michael was a very talented musician with a passion for playing the guitar as well as writing his own music. His favourite past times were going to open-mic nights and performing in different musical bands.
"Michael developed a close group of friends through this. He was patient and thoughtful, often taking time to teach friends the guitar. He loved challenges and was looking forward to his future and plans to travel."
Clair Hilder, who represented the family, said: "Going on leave both within hospital grounds and within the community is an important part of ensuring that patients are ready to be discharged but sadly in Michael’s case inappropriate precautions were taken to ensure he would be safe while on leave and he was able to leave the hospital.
"Michael’s parents’ primary concern through the inquest process has been on making sure that lessons are learnt and we hope that the Jury’s criticisms which were not reflected within the Trust’s own internal investigation into the circumstances of Michael’s death result in further reflection by the Trust on their policies and procedures."
A spokeswoman for CWP said: "Our deepest condolences and our continued thoughts remain with Michael’s family. Following Michael’s tragic death, CWP fully engaged in a Trust investigation and have implemented recommendations identified to address the concerns raised. Following the inquest the Trust will further review learning identified from the inquest."
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