Christopher Stevens · Prevention of Future Deaths report

On 21/6/23, I concluded an inquest into the death of Christopher Stevens, aged 58, who was found deceased on 1/1/22.
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The medical cause of death was recorded as:
1a) Exsanguination
1b) Multiple incised wounds

I recorded a Conclusion of Suicide.

Chris had enjoyed a long period of relative stability with his mental health until 2020/21. In the period that followed there were two serious attempts at overdose both of which resulted in lengthy admissions into ICU. He was admitted to Longreach and was known to the in-patient team.

On 6/1/23, he was admitted into RCHT following an overdose. He was then transferred to Longreach and admitted on to Perran Ward on 22/1/23 before being transferred to Carbis and Cove wards on 25/1/23 and 6/2/23 respectively.

He was admitted as an informal patient and, prior to his transfer to Cove ward, had a number of episodes of escorted leave.

On 8/2/23, the inquest heard that Cove ward was understaffed with only one of three rostered nurses due to attend. Accordingly, the ward manager, ████████, came to work early to assist her nursing colleagues. While treating another patient with suspected sepsis, Chris requested leave to go into the hospital’s grounds. ████████ accepted in evidence she had not had time to read Chris’s Rio records and she did not then appreciate that his previous leave had only been escorted. She delegated to an HCA, in effect, to check that leave was appropriate before authorising it without conducting her own assessment of risk.

There was a short delay in appreciating that Chris had not returned to the ward as anticipated. His body was discovered three days later.

The Trust has conducted a PSIR the contents of which were reviewed at inquest. The report reached conclusions I found entirely reasonable. I also heard from ████████ about the steps that are being taken to implement the changes felt to be appropriate. This includes a change to the consultant model with one consultant now responsible for the individual wards. There is also an initiative to standardise documentation, for example, at handover, and later MDT (when risks are reviewed), to ensure this is incorporated into Rio, together with an express intention to involve the family in decision-making. It was accepted that risk should be assessed by a nurse prior to granting leave to an informal patient particularly where escorted leave is being considered for the first time.

Although Chris’s death occurred in February 2022, it also became clear that the process had not been completed. It was hoped this could be achieved by the end of July this year but the inquest was told there would need to be consideration of the proposals by the different consultants now involved. I was concerned to ensure that the process was completed without undue delay and it is with this in mind that I now write to you.