Witnesses recalled in inquest on Oswestry police sergeant Lee Johnson
A coroner took the unusual step of recalling six witnesses to ask them to spell out what changes there had been in their working practices following the death of a patient in a psychiatric unit.
The surprise move came at the end of a two-day inquest in to the death of Oswestry police sergeant Lee Johnson, who hanged himself while a voluntary patient on the Heddfan unit at the Maelor Hospital, Wrexham.
Sgt Johnson, 45, had been a patient for two months, having been suffering from depression, and the inquest was told that when under the influence of alcohol he became suicidal.
He told staff and his wife Barbara that he felt safe in hospital, but he was known to have taken alcohol on two occasions while in Heddfan and was suspected of having been drinking on several other occasions.
At the close of the inquest, in which he recorded a narrative verdict, John Gittins, the coroner for North Wales East and Central, said the unit had “entirely failed to address the risk he posed to himself, especially after consuming alcohol” and that the policy on patients taking alcohol onto the unit needed to be far more robust.
“As an outsider it is hard to understand how a person can be intoxicated in Heddfan,” he said.
Earlier consultant psychiatrist Dr Stuart Porter, interim clinical director with the Betsi Cadwaladr University Health Board, outlined the improvements introduced in an action plan covering such matters as observation of patients, more one-to-one sessions, better documentation and liaison with family members.
Asked by barrister Charlotte Law, representing Mrs Johnson, whether the risk to her husband had been underestimated in the light of previous incidents when he had been drinking, Dr Porter replied: “Potentially yes, but predicting a risk is difficult. It is my view, and that of the panel, that more challenging conversations could have taken place about alcohol,” he added.
The inquest heard that Sgt Johnson, a father of two, of Cilcain Road, Pantymwyn, near Mold, had been a “model patient” but he did not accept that alcohol was an issue.
Just a few hours before he died in February last year, he had bought flowers and a Valentine’s Day car which he had planned to give to his wife the following day.
After reading his narrative conclusion the coroner said that he had initially wondered whether there had been a systemic failure of policies and procedures but having reconsidered the matter he felt that the existing policies were good and would work in practice.
After the hearing Mrs Johnson, herself a serving officer with North Wales Police, said: “Whilst I am encouraged that the Health Board have conducted a very thorough and transparent review, having heard evidence from staff that treated Lee at Heddfan I feel they have not recognised the failings in his care that I believe contributed to his death. The loss of Lee has been catastrophic to me and my family.”
Dr Stuart Porter said: “We offer our sincerest condolences to the family of Mr Johnson.
“We fully accept the coroner’s findings and will ensure that we will respond to the concerns he has raised in respect of the way Mr Johnson’s care was managed and the need for more rigorous implementation of policies.
