Mental health hospital's failings contributed to young Shrewsbury man's death, coroner concludes

Shropshire Deputy Coroner Heath Westerman recorded a conclusion of suicide at the inquest into the death of Jack Doran, 28, from Shrewsbury.

But Mr Westerman said that a number of failures at Shrewsbury's Redwoods Centre mental health hospital had contributed to Jack's death.

The coroner said that Jack's mother, Jane Bright, and his sister, Charley Doran, had both been to the hospital to express concerns to staff just days before he took his own life.

Mr Westerman said that those concerns were not passed on – preventing the possibility for senior clinicians to reassess him.

The coroner said that on the day Jack took his own life, he had been allowed to walk out of the Laurel Unit at the hospital without anyone noticing.

The two workers on duty were temporary, due to staff shortages, and the correct procedures were also not followed when it was realised he was missing – three hours after he was last seen.

The hospital also did not have Jack's mobile phone number, with staff having to call his mother to get it.

Mr Westerman added that the hospital had failed to assess Jack's suitability for unsupervised leave.

The coroner did though rule that he was satisfied that the hospital now has procedures in place to prevent a repeat.

Matron Adam Chambers had earlier told the coroner that the trust had implemented a total of 18 recommendations to address the failings.

Giving evidence, Matron Chambers had said: "Unfortunately at the time of Mr Doran going missing it is correct to say that the trust did not follow the policy that was in place."

The inquest heard that Jack had suffered with his mental health for a number of years.

He had previously tried to take his own life, and had been admitted to Redwoods before.

His admission on August 23, 2022, came at his own request, due to suicidal thoughts.

Mr Westerman heard how Mrs Bright and Miss Doran had both expressed concerns to staff at the centre on August 31 – but those were not passed on and Jack was able to leave unhindered and unnoticed just days later, on September 4, with tragic consequences.

The coroner recounted how he had heard evidence from Alison Blofield, the consultant nurse and approved clinician in charge of Jack's care, that she would have approached his treatment differently if she had been told of the family's worries.

Mr Westerman said: "Alison Blofield met Jack outside on September 1 in the smoking area and had an informal chat with him. At the time she was not aware of the concerns expressed by the family the previous day.

"Had she known, she would have asked him different questions that day. She was aware of the general concerns about suicidal ideation but nothing specific from the family."

The coroner said he was satisfied that Jack had intended to commit suicide – pointing to the evidence of his family, and other matters which pointed towards an intentional act, and would be recording a conclusion of suicide.

Delivering his conclusion, Mr Westerman detailed the failings at the centre that had contributed to Jack's death.

He said: "First, the family concerns about Mr Doran's safety due to suicidal thoughts and messages sent on August 31, 2022, were communicated to a member of staff at the Redwoods Centre. These concerns were not communicated to the relevant treating clinicians, consequently appropriate action was not taken in relation to treatment to reflect the increase in risk that he might self harm."

The coroner said the second failing was that no assessment was carried out of Jack's "suitability for unsupervised leave when there ought to have been".

He added: "Third, no details were recorded – where he was going, why, how long for, and what his contact details were, when they ought to have been.

"Fourth, staffing shortages on September 4 were filled by temporary bank staff, not familiar with the Redwoods Centre guidelines and policies on missing persons. Consequently the correct procedures were not followed – this involved a lack of escalation, search, reporting, ownership, leadership and accountability."

Mr Westerman said he was satisfied that the as a result of Jack's death the trust had now put in place appropriate procedures to prevent the failings being repeated.

He said: "I have been impressed by the depth, candour and transparency from the trust in that serious incident report and statement, and evidence from Matron Chambers. It is clear to me from the evidence that the trust had been faced with a number of challenges at the time it was responsible for Jack.

"It is clear that since his death, much work has been done as outlined by the 18 recommendations and actions that have been completed.

"It is, however, always sad when it takes the death of a young person such as Jack to be the catalyst and initiative for such change."

*Whatever you're going through, Samaritans are there – day or night, 365 days a year. You can call them for free on 116 123, e-mail them at jo@samaritans.org, or visit samaritans.org to find your nearest branch.

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