Andrew Gibbins · Prevention of Future Deaths report

On 6 March 2020 I commenced an investigation into the death of Andrew Gibbins, 54. The investigation concluded at the end of the inquest on 1 December 2020. The conclusion of the inquest was that he died from multiple skull and rib fracture with pneumothorax due to a road traffic collision and that he had taken his own life.

On 15.01.2020 Mr Gibbins who had a long history of mental health informal admissions ran into the path of a lorry on the A14 Westbound. Eye witnesses confirmed that his actions were deliberate. His injuries were incompatible with life. Recognition of Life Extinct (ROLE) at 20:50 hours. Mr Gibbins had been unescorted awaiting test results on Acute Assessment Unit (AAU). He had expressed to a security guard that he was feeling suicidal and that was why he was under Wedgewood unit. He appeared withdrawn but this information did not reach Wedgewood or the Staff Nurse.

(1) The Hospital Security Guard guided Andrew Gibbins back to AAU looking lost and confused (following a cigarette break) when in general way saying that he was feeling suicidal and that that had been the reason why he was under the care of Wedgewood. There were no immediate concerns for him, but the Security Guard had been concerned enough to ask for the Wedgewood staff member escort when he returned to AAU. Andrew's presentation had not been reported to any clinician at either AAU or Wedgewood.