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Kent NHS trust apologises for man's mental health care failures


A coroner has issued a prevention of future deaths report after a man took his own life following inadequate care because of a shortage of mental health nurses.

When the patient, Ben Hart, 25, died at his mother's home near Dover in October 2022, there should have been 16 mental health care nurses available in East Kent, but there were only six on the rota, an inquest heard.

Ben Hart had been sectioned and admitted to Coleman House, Dover, after an attempted suicide in 2021.

But an inquest at Maidstone County Hall heard in the following months there were delays in appointments, missed opportunities for treatment and a lack of coordinated care.

Following this incident, he was placed with a new care coordinator for issues including Post Traumatic Stress Disorder (PTSD) general anxiety, and enduring personality change after a catastrophic life experience. His previous social worker had gone on maternity leave.

However, his relationship with his new coordinator began to fail after several periods of not being contacted by the trust, sometimes for months at a time.

There was also a referral for a test for autism spectrum disorder (ASD) that was requested in February 2022, and not acted upon until September.

Representatives of KMPT said that Ben Hart’s new care coordinator was unable to fulfil his care plan, which involved a monthly visit, which was meant to increase to once a week if new medication was issued, as staffing difficulties had left her having to carry out multiple roles.

The shortages were so severe that, at the time of Ben Hart’s death, KMPT, said to normally operate with 16 full-time nurses, had only had eight, with two of these on long-term sick leave.

Due to these issues, there was sometimes up to two months when no mental health professional from the trust contacted Ben Hart. This included a gap from June 27 to September 5, at a time when he should have been seen once a week.

The perceived lack of care led to a total breakdown in the relationship between Ben Hart and his care coordinator who he submitted a complaint about on September 13. He was never contacted by the trust again. Two of his eight carers could not be replaced due to staff shortages.

His mother, Anna Kerley, phoned the crisis team on 11 October and left a message, but the call was not responded to. She phoned again the following day and requested an urgent call back.

They eventually called back on 14 October, two days after Ben Hart had taken his own life.

Senior central and south east Kent coroner, Patricia Harding, who recorded a suicide verdict, detailed a series of delays and missed opportunities for treatment, and highlighted staffing shortages at the trust.

She said: "They were 10 nurses short. Resources were significantly stretched. This shortfall endures and staffing levels at the time of his death were such that Ben was not provided with the service he should have been."

Kent and Medway NHS and Social Care Partnership Trust said action had been taken to address failings.

A trust spokesperson also apologised "unreservedly" to Mr Hart's family, adding: "The safety of those we care for is our utmost priority and we recognise that we fell short of that on this occasion."

Anna Kerley said “nobody listened” to her son who she said felt "incredibly let down" by the mental health service he received. She added: “Nobody listened to him. It was almost like they gave up on him.”