Stuart Michael CLARK · Prevention of Future Deaths report

On 3 October 2017 an investigation was commenced into the death of Stuart Michael CLARK. The investigation concluded at the end of the inquest held on 2 April 2019. The conclusion of the inquest was as follows:

Suicide

Stuart Michael CLARK had a long history of suffering with his mental health. On 3 October 2017 he had input into the canal at Haven Road, Exeter wearing a rucksack filled with weights. He was recovered from the water and taken to the Royal Devon and Exeter Hospital where he sadly died shortly after arriving.

More specifically, Mr CLARK had a history of Asperger’s Syndrome, Dyspraxia, Developmental Dyslaxia and Irlen’s Syndrome. In the weeks before he died he complained of a rash, pain and swelling believed to be an allergic reaction. On 30 September 2017 he was admitted to the Royal Devon and Exeter Hospital due to pain, swelling and a history of diarrhoea and nausea; on assessment he was extremely anxious and concerned about his physical illness. During his admission he disclosed to a nurse on the ward that he was a vulnerable adult and a suicide risk. This information was not escalated, and no assessment was made to determine his risk of self-harm and suicide.

(1) The evidence revealed that Mr CLARK disclosed to a member of nursing staff on Lowman (Canpere) Ward at the Royal Devon and Exeter Hospital that he was a vulnerable adult and a suicide risk. This disclosure was not followed up with an assessment to determine if Mr CLARK had any intent, plan or history of self-harm or suicide. An assessment would have helped determine his risk and inform the decision on a referral to mental health services.

Senior clinical staff were not directly informed of the disclosure. The SHO Dr responsible for Mr CLARK stated in her evidence that had she known about the disclosure she would have assessed his risk of self-harm and suicide, and if appropriate she would have referred him to the mental health services.

The nurse made an entry in the medical records; however, the medical notes were not made up until the end of the day and therefore the information was not available to the other staff at the relevant time.