Mental health hospital 'failed to pass on mother's concerns son would kill himself days before he died'

The hearing into the death of Jack Roderick Doran, from Shrewsbury, heard of a series of issues in the care provided at the town's Redwoods Centre, when he was admitted to the Laurel Ward on August 23 last year.

Shropshire's Assistant Coroner Heath Westerman was told that the Midlands Partnership NHS Foundation Trust (MPFT) which runs the centre, had already carried out 18 recommendations for improvements following its own investigations into failings in Jack's care.

The 28-year-old former Belvidere School pupil had previously been diagnosed with schizophrenia and had suffered with mental health issues for a number of years.

The inquest heard he had previously attempted to take his own life, resulting in him being admitted to the Birch Ward at Redwoods in 2021.

He had subsequently been discharged, and was living the Sunnydale residential care home in Craven Arms, when his condition deteriorated in August last year.

The inquest was told he was admitted to Redwoods after personally requesting to be moved to the facility.

Evidence at the inquest revealed that he had told a mental health team assessing him that he would kill himself if he stayed at Sunnydale.

Mr Westerman was told that Jack's mother and sister had then telephoned and visited the Redwoods Centre on August 31 to warn staff that he had suggested to family members that he planned to commit suicide.

They had also asked for staff to not let him out of the premises after friends had reported seeing and meeting him outside the facility in Shrewsbury.

But, the inquest was told the concerns were never passed on to the senior clinician in charge of Jack's care.

The situation meant that Jack had remained a patient on an 'informal' basis, and was allowed to leave the site on his own, instead of effectively being detained for his own safety.

The coroner was also told that even though Jack had 'informal' status, the hospital should still only have allowed him to leave after approving his request – and finding out where he was going and when he would be back.

This did not happen on September 4, when Jack left sometime before 10am, and was found later that day, having taken his own life.

The inquest heard that official procedures requiring a search of the site were not followed even after he was discovered missing, and the matter was not escalated appropriately to senior staff.

It also emerged that the hospital trust did not have Jack's mobile telephone number in his records – despite him having been a patient for four years – and had to ring his mother to try to get it as they sought to find out where he had gone.

Mr Westerman heard evidence from Alison Blofield, the consultant nurse and approved clinician who was in charge of Jack's care.

She explained that she had seen him smoking in an outside part of the facility on September 1, and had ended up having a lengthy conversation in which she assessed his condition.

Ms Blofield told Mr Westerman that she was not aware of the "specific detail of concerns" raised by his mother and sister at that point, and that they had not been passed to her.

She said that had she known then her line of conversation would have been different, adding that if she had not been reassured that suicidal thoughts were 'fleeting' she would have recalled him immediately – meaning he would no longer be able to leave the site.

But, she also told Mr Westerman that there was nothing in her conversation that made her concerned he was a risk to himself.

She said: "Jack told me he felt better than he had from the last time he was in hospital. This I could agree with, having seen him distressed when he was on the Birch Ward last year."

The inquest also heard evidence from registered nurse Laura Scandiato, who had spoken to Jack's mother on August 31 when she had requested that he be kept at Redwoods for his own safety.

The nurse said she had included the information in her verbal handover to the night shift, and had then spent 20 minutes speaking to Jack during her shift the next day, on September 1.

She said that during the conversation she had questioned whether he was a risk to himself, and that he had replied by saying his 'mum was worrying over nothing'.

Ms Scandiato told the coroner she had no concerns about his presentation, adding that they had discussed plans for the future, and football and his favourite team.

She said the information from the discussion was relayed verbally to the nurse in charge of the ward.

The inquest also heard that the facility was suffering with staffing shortages and that both senior nurses on duty on the day Jack went missing had been 'bank staff' – meaning they were temporary staff drafted in, and were not permanent on the ward.

Sandra Gonnelly, who carried out the MPFT investigation into Jack's care, said there was not enough concern when it was realised Jack was missing.

She said: "This prolonged absence should be notified to qualified staff. There was no curiosity around where he was or checking with staff if he had made any plans to leave the grounds."

After hearing of changes made in the wake of the case, Mr Westerman said he was "heartened" by the trust's actions but said he wanted clarity over why Jack's mother's concerns had not been passed to the appropriate person – saying without assurance that processes are in place to avoid a repeat, it could lead to a future death.

He said: "I still have concerns from all that has been highlighted, thought about and documented, I still have a concern about the information the family gave to the hospital and how that was not passed on to the most appropriate people staff-wise."

Addressing Redwoods matron Adam Chambers, he said: "I mean no disrespect to the staff, but if the family report matters to a low grade member of staff because they are the only ones around how do you ensure that information from the family goes to you as matron or the approved clinician?"

The hearing was adjourned until later this year.

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