Hospital failed man who fell to his death, coroner says.

Action must be taken at a hospital where a suicidal man fell to his death, a coroner has warned. 

Aaron Deeley, 43,  a patient at at Southend University Hospital died in January 2022 after falling from a second-floor window, which was known to be faulty.

Mr Deeley had several known suicide attempts and was meant to be under one-to-one observation, however this was removed hours before his death.

Mid and South Essex NHS Foundation Trust (MSE) admitted failings in his care during an inquest and said action had been taken.

In a Prevention of Future Deaths (PFD) report, Essex area coroner, Sonia Hayes, said there had been "failings in the care and safeguarding" by the trust which contributed to Mr Deeley being able to take his own life.

Mr Deeley was an inpatient in Southend's acute medical ward and was awaiting an assessment by the Mental Health Liaison team from Essex Partnership University Trust (EPUT).

A jury concluded that there had been several issues in Mr Deeley's care including inconsistencies in completing the medical ward's enhanced observation form on the day before his death. 

The jury also said that, after a previous suicide attempt in December 2021, there was insufficient detail from Southend Hospital in his discharge letter and the discharge paperwork from the mental health team was sent to the wrong GP address. 

The coroner highlighted there had been confusion from the medical trust about what was required to ensure a patient waiting on a Mental Health Act assessment could be put under one-to-one observation and that Mid and South Essex Trust's policy on the issue was "confusing."

Ms Hayes said: "There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety."

Chief executive of Mid and South Essex NHS Foundation Trust, Matthew Hopkins, said a full investigation took place following Mr Deeley's death. 

He said: "We have improved our policies and procedures to ensure the safe supervision of mental health patients on our wards. Immediate action was taken to secure the windows and appropriate action has been taken to ensure that our windows are safe for all patients.”

EPUT chief executive, Paul Scott, said the trust would look at the coroner's recommendations and was "committed to ensuring patients receive the right care at the right time."

He said the trust's mental health liaison teams worked closely to ensure patients received the most appropriate mental health support to meet their individual needs.