David Hackman · Prevention of Future Deaths report

On the 10 September 2013 I concluded the Inquest into the death of David Hackman who was born on the 11 November 1937. I determined that the cause of death was that David died from multiple traumatic injuries as a result of a fall from a height. My conclusion as recorded on the Record of Inquest was that David Hackman took his own life.

The circumstances of his death were that David had got into financial difficulties. He had no history of depression but on the 23 June 2013 he took up to 32 paracetamol tablets at his home address before alerting the emergency services and in particular the ambulance service. They arrived at about 1700 hours the same day and took David to the Accident & Emergency Department at the Great Western Hospital in Swindon. Attending medical personnel undertook and internal assessment that triggered contact being made with the supplier of mental health services, The Avon & Wiltshire Mental Health Partnership, and a mental health assessment was undertaken early evening the following day, Sunday 24 June 2012. Earlier that Sunday morning David had made a couple of attempts to walk off and outside the Ambulatory Care Unit before being guided back to the observation unit by a Staff Nurse. David fully cooperated during the mental health assessment and was not found to be suffering from any mental illness and presented no continuing suicidal ideation. At approximately 11.35 the following day David got dressed and walked out of the Ambulatory Care Unit unnoticed before boarding a bus at 11.40 that took him into the centre of Swindon. He got off the bus, climbed to a 3rd storey on a nearby multi storey car park before jumping off the multi storey car park to his death at approximately 12.15 the same day.

At the end of the Inquest I heard evidence as regards the concordance of voluntary arrangements that were established in 2004 and as regards the national reporting and learning service but I am concerned here as regards how this specific incident and in particular its lessons are being disseminated to the wider health care community in England & Wales and in particular other Trusts. I understand the general principle but I would be grateful if you could please specifically explain relevant to this particular incident and the learning exercise that’s been carried out as to how the lessons learned have been communicated and if they have not been communicated to review as to why no action is being taken in that respect with a view to the prevention of future deaths.