Roger Clive DUGGAN · Prevention of Future Deaths report

On 15th February 2013 I commenced an investigation into the death of Roger Clive DUGGAN, Aged 61 years. The investigation concluded at the end of the Inquest on 5th March 2014. The conclusion of the inquest was Open Verdict: The Deceased was in a heightened anxiety state when he absconded from cubicle 8 in the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours 11th February 2013, after which, at some point, he entered the River Exe opposite Mill Lane. He also had ischaemic heart disease.

10/2/13 Wife had given him 2 x Diazepam approximately 2100-2130hrs and kept the packets in her handbag. He was in a very agitated state, pacing. Wife rang the crisis team who suggested they call 999, he said to his Wife "he wanted to get out and would not be back". After some considerable delay the Ambulance arrived and he was taken to A&E Minors RDE via ambulance late that night, but absconded from the department via main entrance at 0047hrs 11/2/13 and is shown on CCTV to leave the site shortly afterwards. An extensive search was carried out by Police in the area with no sightings. 12/2/13 Mr Duggan's body was located by a group of canoers in the water at a tributary to the River Exe, opposite Mill Lane Exeter, his body was recovered by joint emergency services and confirmed deceased at 1430hrs. Police happy no suspicious circumstances. Deceased's glasses were found, intact in his pocket. Wife states he always wore them and believes he took them off purposefully.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) Whilst it was apparent in evidence that matters had reached fever pitch at Mr Duggan’s home, The Lindhay, The Old Farmhouse, Bramford Speke, on the evening of the 10th February 2013 as he reached a severe anxiety state. The family were firmly of the view the initial calls to Ambulance Control were not treated sufficiently seriously (despite the family being advised to do so by the Crisis Team). An ambulance visit only materialized after a further call to the Crisis Team and the latter’s instruction to Ambulance Control to attend.
It appears that staff lacked the necessary training to deal with Mental Health Crisis. After subsequent arrival at the Royal Devon and Exeter Hospital (Wonford), Accident and Emergency Department, later that night 10th February 2013 Mr Duggan absconded only to be found deceased in the River Exe at 14.30 hours 12th February 2013.