Peter Jonathan Wright · Prevention of Future Deaths report

On 3 December 2013 I commenced an investigation into the death of Peter Jonathan Wright aged 49 years. The investigation concluded at the end of the inquest on 26 February 2015. The conclusion of the inquest was ‘suicide while suffering severe depression and psychosis’.

Mr Wright was certified dead at 22.40 hours on 29 November 2013 at St George’s Hospital in Stafford. He had been a voluntary patient there and had deliberately cut an artery in his neck using a broken metal fork. He had been observed by staff shortly prior to the incident but because of work pressure on staff the observations had not been recorded. No doctor from the hospital was available to attend the scene.

(1) At the time of the death the ward was understaffed. Of the quota staff of three, one care assistant had been called to assist in another ward (and had in fact just returned) and one care assistant was with another patient who required continuous observation. This left just the qualified nurse to deal with 16 patients. She did not record all necessary observations and was doing a drugs round by herself (contrary to policy). This was recognised in the SIR carried out by ████████ but no recommendation was made about it on the basis that the Trust was undergoing a major staffing review in any event. It may therefore be that the situation has already been addressed but this was not clear to me at the Inquest and the impression I received from the nurse was that there is now some extra support at times but it is still not satisfactory.
(2) At the time of this incident there was still a 24 hour Emergency Department at the nearby Stafford Hospital and at St George’s Hospital there was no doctor on site. Now the Emergency Department at County (formerly Stafford) Hospital is not open during the night and the nearest ED is at Stoke. I was told that the situation can be managed by calling paramedics. While I appreciate that nearly all the doctors at St George’s are psychiatrists not medics I wonder if any consideration has been given to out of hours cover by a doctor?