Psychiatric hospital "missed chances" to save suicidal patient

It was left to the family of self-employed sign writer Timothy Alexander Painter to report him missing... but by then it was too late.
And at a three-day hearing into his death this week, Berkshire coroner Peter Bedford outlined a catalogue of failings at Prospect Park Hospital in Tilehurst which, he ruled, probably contributed to his tragic end.
The body of Mr Painter, aged 41, who lived with his family at Meadowside Road in Pangbourne, was discovered 22 days later on April 12 last year by a rambler in Bartholomew Woods in Tidmarsh.
He was last seen on the morning of Thursday, March 21, when he persuaded staff at the hospital run by Berkshire Healthcare Foundation Trust (BHFT) to allow him out, unescorted.
His grieving parents and long-term partner, Emily Broun, believed he should never have been allowed out, having expressed his intention to take his life in the precise manner of his ultimate demise.
And at the conclusion of a three-day inquest into his death at Windsor Guidhall yesterday, family solicitor Denise Broomfield said they felt vindicated.
The hearing was told that Mr Painter was admitted to hospital on Saturday, March 16, suffering from anxiety and suicidal thoughts.
However there were no beds available at Prospect Park, so he went to a ward in Heatherwood Hospital in Ascot, until one became available.
He was admitted to Daisy Ward in Prospect Park on Monday, March 18.
The hearing was told that, three days later, Mr Painter was given permission to leave the ward, ostensibly to so some shopping.
Nurse Jessica Reeve, who has since left the country and was unavailable to give live evidence at the inquest, made the decision to allow Mr Painter to leave.
She said in a statement she tried to ask advice from a doctor – but none was available.
Instead, the inquest heard, she asked her ward manager Albert Zvenyika, for advice.
Mr Zvenyika then agreed to allow Mr Painter to leave unescorted without ever seeing him, reviewing his notes or checking with his family – with tragic consequences.
Mr Bedford indicated there were numerous missed opportunities to assess Mr Painter and said he could either have been delayed while a consultant or doctor was sought, or could have been persuaded to wait, given how well he complied with his treatment and his insight into his condition.
The inquest also heard Mr Painter’s level of observation was downgraded from four times an hour to once an hour without a senior clinician being consulted, contrary to hospital policy.
As a result, said Mr Bedford, “the clear possibility of the risk Mr Painter presented to himself wasn’t appreciated”.
Recording a narrative verdict, Mr Bedford ruled Mr Painter took his own life and added: “I believe if he had been properly assessed by a senior doctor, on the balance of probability, he would not have been granted leave – either because he would have admitted suicide plans, or he could have been persuaded to stay on the ward.”
He said he did not have to exercise his powers to offer advice to prevent further deaths because he was satisfied that the hospital trust had already “worked very hard to learn lessons and move forward with changes to tra.ining and policy and procedures”.