A tragic case has emerged as a coroner has ruled that the failure to communicate an extension to a patient’s stay at a mental health unit contributed to his suicide. Gareth Etchells-Height, a 42-year-old man with Asperger’s syndrome, took his own life at the Wainwright Centre in Sheffield. The inquest revealed that he was distressed about being sent home, highlighting the importance of clear communication in mental health care.
During the inquest, it was discovered that the handover notes from the previous ward did not adequately inform the staff at the Wainwright Centre about Mr Etchells-Height’s mental health. Crucial information, such as his diagnosis of non-organic psychosis and high-risk behaviors, was not included. Furthermore, the staff at the Wainwright Centre, who were not clinically trained, were not aware of the importance of medication compliance. These failures to provide a comprehensive picture of Mr Etchells-Height’s mental health contributed to his tragic outcome.
The inquest also raised questions about the delay in Mr Etchells-Height’s admission to an acute mental health unit. Despite his history of mental health problems and an incident at a train station, his admission was delayed, leaving room for missed opportunities in his care. The coroner specifically highlighted the failure of the early interventions team to assess Mr Etchells-Height face-to-face, opting for phone assessments instead.
After his symptoms stabilized, Mr Etchells-Height was discharged to the Wainwright Centre for additional support. However, the handover notes provided to the staff at the center did not adequately inform them about his mental health, risks, and medication needs. These missed opportunities in his care were attributed to poor clinical judgment rather than neglect, according to the coroner’s findings.
Tragically, the coroner concluded that Mr Etchells-Height had intended to take his own life, and the failure to communicate his extended stay at the Wainwright Centre contributed to his death. The family of Mr Etchells-Height described him as an “incredibly special” person with unique interests and capabilities, leaving a void in their lives.
The Sheffield Health and Social Care Trust, responsible for the Wainwright Centre, has not yet commented on the ruling. However, this case highlights the need for improved communication and comprehensive handover procedures in mental health care facilities. It is crucial that all staff members, regardless of their clinical training, are adequately informed about patients’ mental health conditions, risks, and medication requirements to ensure the best possible care and prevent tragic outcomes.
If you or someone you know has been affected by the issues raised in this article, the BBC Action Line provides links to organizations that can offer support and advice. It is essential to reach out for help and support during difficult times.