Mental health bosses failed father, family told at Leicester inquest

Mental health bosses failed to provide basic medical attention to a patient who killed himself after walking out of hospital, a coroner has ruled.

Gagandip Singh Sandhu absconded from the Bradgate Unit, at Glenfield Hospital, after being left alone by staff. He was found hanged in Knighton Park.

Yesterday, at the end of a three-day inquest into his death at Leicester Town Hall, coroner Catherine Mason said the Leicestershire Partnership NHS Trust, which runs mental and community health services in the county, was at fault.

Mrs Mason said there was "a gross failure to provide basic medical attention to Mr Sandhu at a time when his mental condition was such that he needed it".

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The coroner said: "When Mr Sandhu absconded, it was known, or should have been known, by all in whose care he was detained and trusted by his family, that there was a real and immediate risk to the life of Mr Sandhu from self-harm – and yet the plan of care prescribed to keep him safe was not followed."

The hearing was told how Mr Sandhu, 55, of Skelton Drive, Knighton, was left unaccompanied in a day unit on November 18 last year, when he should have been escorted at all times.

Registered nurse Clara Foromani, who was working as a health care support worker provided by an agency, told how she took Mr Sandhu off the Bosworth ward, at the Bradgate Unit, at about 9.45am. She admitted she did not check on his status, which would have told her he was on "escorted leave" only – meaning he had to be accompanied at all times when off the ward.

Detective Constable Steven Hadden, who investigated the death, said Mr Sandhu had simply walked out of the front door of the hospital.

He said Mr Sandhu, a father-of-two, was found hanging from a willow tree in Knighton Park by a member of the public at about 3.40pm.

Mrs Mason said Mr Sandhu had taken his own life, but recorded a narrative verdict rather than one of suicide.

After the hearing, Mr Sandhu's family spoke of the great loss they felt at his "preventable" death.

Daughter Priya Sandhu, who wept as she gave evidence in court about making the call which led to her father being sectioned under the Mental Health Act, said she was devastated.

Ms Sandhu, 27, of Knighton, said: "We left my father in the care of these people and they failed him badly. We thought he would be safe. He was not.

"Perhaps the worst part is that his death could have been avoided if people had done their job properly. We hope lessons are learned so his death was not in vain."

After the hearing, Leicestershire Partnership NHS Trust chief executive John Short admitted there had been "significant failures".

He said: "The Trust fully accepts the coroner's verdict stating that there were significant failures relating to staff communication and professional conduct that would have prevented Mr Sandhu leaving the unit and taking his own life.

"Recommendations and actions from our investigation have resulted in a number of improvements."

Mr Sandhu's inquest is the second into the cases of seven people with mental health issues who died while in the care of the Leicestershire Partnership NHS Trust.

The five women and two men, who were aged between 19 and 55, died in a 19-month period between November 2010 and June this year.