Peter James FAREBROTHER · Prevention of Future Deaths report

On the 30th May 2014, with a Jury, concluded the Inquest into the death of the late Peter James FAREBROTHER. The Jury returned a narrative conclusion as follows:

The deceased Mr Peter James Farebrother took his own life whilst the balance of his mind was disturbed. In addition it is the decision of the Jury that the risk of returning Mr Farebrother’s belt and placing Mr Farebrother on general observation was not fully recognised. These two factors combined contributed to Mr Farebrother’s death.

The late Mr Farebrother had been admitted as an emergency patient to the Redwood Centre on Oak Ward the 17th July 2013. He was admitted to Holly Ward 2 days later with the intention of later being admitted to Pine Ward. That transfer did not take place until the evening of the 22nd August 2013. 2 days later on the 24th August 2013 Mr Farebrother was found deceased hanging from a belt ligature attached to the en-suite shower door in his room (room 11) at Pine Ward.

(1) The delayed transfer to Pine Ward coming at the end of an evening shift prior to handover to the night shift.

(2) The failure by the receiving staff on Pine Ward a) during the remainder of the evening shift or b) at any time during the night shift to recognise that Mr Farebrother had been on constant watch up to and including the transfer and that no assessment had taken place changing that status.

(3) The lack of personal knowledge in the handover procedure and the limited time the assessing assistant practitioner had at the start of the morning shift to read Mr Farebrother’s papers.

(4) The assessment may well have resulted in a higher observation level and the basis on which it was made, consciously or subconsciously, may have been flawed by the earlier breakdown in information.

(5) The decision to return the belt to Mr Farebrother. It was the same belt which a) Mr Farebrother later hanged himself with and b) had resulted in Mr Farebrother having been on constant observation at Holly Ward. Whilst other ligatures may still have been available to Mr Farebrother by removing the belt the most obvious ligature would have been avoided.

(6) The perception that Pine Ward may be ligature free may have lowered risk awareness. Staff may have felt that the need for higher observation and/or ligature avoidance had been reduced by the environmental safety features on Pine Ward itself, whereas the underlying risk remained.

(7) The sloping door was intended to prevent or reduce the risk of hanging. Mr Farebrother’s case has indicated that this is not so. No change has been made to the door and it is therefore possible that this means of ligature attachment could happen again. The door was manufactured and delivered for purpose and therefore this concern should also be shared with the manufacturer. Consideration should also be given whether there is a need for an en-suite shower door, balancing the patient’s rights of privacy and dignity over risk of self-harm.