A man with a history of mental health issues “did not receive the assistance he needed” while at a hospital’s emergency department before his death.
A coroner found acute and mental health teams “fell far below” the care expected when Daniel Venes was brought to the Queen Elizabeth The Queen Mother hospital (QEQM) in Margate, Kent, on August 13 2021 after he was found distressed at a train station.
The 31-year-old artist absconded from QEQM the following day while he was awaiting a review by a separate mental health unit.
His body was discovered by French police on a beach on August 28 but was not identified until the following January.
Coroner Sarah Clarke concluded it was “unclear” how Mr Venes came to be in the Channel but confirmed his medical cause of death as drowning.
She told the inquest at Maidstone County Hall Mr Venes would have likely been admitted to hospital for a relapse in his schizophrenic condition if he had undergone the review.
Ms Clarke said Mr Venes was “tormented by enduring mental health difficulties” and needed support from various services.
She added: “He had very great support of his family and he was able to, at times, live a relatively normal life.
“He wasn’t on his own but at times his mental illness made him feel alone. This was all creating an endless cycle of episodes of acute psychosis.”
Despite her warnings over the handling of Mr Venes’ case, the coroner said she had “no doubt” systems had improved at the hospital and its wider mental health care but there were still areas needed working on.
The coroner will prepare a prevention of future death report.
UK authorities were not involved in the discovery of his body until January 2022, when Mr Venes was identified.
His family and friends had campaigned to find him for months without knowing he was already dead.
Mr Venes was described as “unique and passionate” by his family, with a “deep interest” in the world around him.
His mother Shaine Venes said his music and art “will live on forever” and that the family hopes to put together an exhibition of his work later this year.
Mr Venes’ uncle, Justin Venes, said the family felt it was the “right verdict” and there was recognition of the “massive failings” in the care supposed to be provided to his nephew.
“Nobody with mental health issues should be forced to be left in a hospital for 22 hours without proper supervision or care,” he said.
Justin Venes added the family were relieved to hear some of the recommendations had since been acted on.
The inquest heard from Jennifer McBride, a matron from East Kent Hospitals University NHS Foundation Trust, that capacity for enhanced observation of mental health patients had been increased since Mr Venes’ death.
The inquest also heard of plans to have ‘safe houses’ for mental health patients in operation by autumn that would be attached to emergency departments to look after such patients while they await referrals.
