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Investigation and inquest
On 21st May 2015 I commenced an investigation into the death of David John Pooley. The investigation concluded at the end of the inquest on 30th October 2015. The cause of death was 1a) Hanging. The conclusion of the inquest was a Narrative Conclusion;- David Pooley killed himself whilst suffering from depression. David John Pooley’s risk of self harm/suicide was not properly and adequately assessed and reviewed.
Circumstances of the death
Mr Pooley who was 66 years old, was admitted to Basildon Hospital on the 5th May 2015 following an attempt to hang himself in his own home. He spent time in the Mental Health Assessment Unit and he was then transferred to Gloucester Ward. He was found hanging in the toilet on the ward and his death was confirmed at 6:38am on the 20th May 2015.
Coroner’s concerns
1. Contrary to the trust’s policy, there was no named nurse allocated until the day before Mr Pooley’s death. The role of the named nurse had not therefore been carried out – this entails the devising of a risk assessment, care plans, one to ones, contact with the patient’s family etc.
2. The appropriate assessments and reviews were therefore not carried out.
Information checked against the published report and official responses