Thomas Whitfield · Prevention of Future Deaths report

On 8th August 2016 I commenced an investigation into the death of Thomas Whitfield, 62 years old. The investigation concluded at the end of the inquest on 19th April 2017. The conclusion of the inquest was Suicide with a cause of death of 1a) Hanging.

The deceased was a voluntary patient at Farnham Ward, Lanchester Road Hospital, Durham, having previously been detained under Section 2 of the Mental Health Act. On the morning of 28th July 2016 there was an incident on the ward which resulted in the deceased being re – assessed by his Consultant Psychiatrist. Within one hour, on a routine observation, the deceased was found hanging in the room. He had not been assessed of been at risk of suicide.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
The deceased’s sister made a statement advising that she had spoken to hospital staff alerting them to the risk that she perceived her brother had of suicide. Her statement states that staff had acknowledged this and were aware of this, were monitoring him and they had been able to listen to his telephone conversations which took place near to their desk. Evidence was given that it would be expected that such calls would be recorded in the Paris notes and acted upon including speaking to the patient. A Consultant Psychiatrist gave evidence that if he had been aware of such family concerns it would have affected his risk assessments. There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns.
Many calls now are recorded for monitoring and training purposes and had such calls being so monitored and or recorded then at least it would be possible to prove one way or the other whether such calls had taken place and what their content was. There is no such monitoring or recording of calls at the present time. There is CCTV in the hospital, which can be viewed after an event to clarify what did/not happen.