Concerns have been raised by a coroner following the death of a "much-loved" son in what was a recently opened mental health hospital.
Sergio Dunkley was voluntarily admitted to Hartley Hospital in Southport on July 24, 2020 following the "deterioration" of his mental health throughout the year. The 45-year-old was placed under regular observation with checks every 15 minutes before this was extended to checks every hour the following day.
The reason behind the change in observations was not recorded by staff and Mr Dunkley's formal written risk assessment was not filled in after August 4. This meant staff did not adequately record their reasoning for assessment of Sergio’s risk of suicide between August 4 and August 17, 2020.
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On August 17 Mr Dunkley appeared to be "significantly anxious" when plans for his hospital discharge were discussed, with the report stating there was a failure by staff to carry out a formal assessment as to whether he was at an increased risk of suicide that day. Mr Dunkley was last seen alive at approximately 12.30am on August 18. He was found to have taken his own life shortly before 1.30am that same morning.
The coroner found three points of concern following the death at the hospital in a report to prevent future deaths. The report said: "(1) That there is no statutory requirement nor any current regulations which specifically require the doors within newly build mental health units to be fitted with ligature alarms.
"(2) That whilst Health Building Note 03-01 as published by the Department of Health gives guidance that “ All fixtures and fittings should be anti-ligature the requirement to do so is not stated to be mandatory.
"(3) That inspection and approval of newly built mental health units contains no mandatory requirement for the checking as to the placement of ligature alarms."
The report was sent to NHS England, the CQC and to the Chief Coroners Office, with all expected to respond to the report before July 7, 2022, after the coroner ruled that action should be taken to prevent similar deaths from happening in the future. The report was also sent to the representatives of Mr Dunkley and the representatives of Mersey Care NHS Foundation.
A CQC spokesperson said: "Following the conclusion of the inquest we contacted the trust to seek assurance on how risks to patients were being mitigated and what actions were being taken to address the coroner’s concerns. The CQC will carefully review the trust response to ensure any further risk to patients are addressed in line with the coroner’s report.
"We will be monitoring the implementation of these actions to ensure they comply fully with the findings of the inquest.”
NHS England was approached for comment.
