I'm concerned about this; very simply Mr Gunner was seriously ill with a history of self harm and suicidal thoughts.
In the run up to his suicide, he told staff repeatedly how he felt and yet he was able to access shoelaces from his property?
I have two problems with this;
Firstly, to anyone used to dealing with a 'place of safety', it should be automatic that things like belts and shoelaces are kept firmly locked away.
Secondly, this 'secure' psychiatric unit has a history of allowing suicidal patients access to things that put them in danger or the chance to leave the hospital.
I assume the jury and the coroner were unaware of these previous incidents;
By Rebecca Shepherd
Get Surrey.
Barry Gunner, 43, killed himself using a ligature, which had been 'readily available' while being detained under the Mental Health Act
A "talented artist" from Godalming, who was diagnosed with schizoaffective disorder, took his own life while detained in hospital under the Mental Health Act, an inquest jury has concluded.
The six-day inquest at Surrey Coroner’s Court into Barry Gunner’s death came to an end on Monday (July 25) when a jury gave a verdict of "suicide".
The jury heard from medical clinicians and nursing staff from the Abraham Cowley Unit (ACU) of St Peter’s Hospital, who looked after and treated Mr Gunner during his 16-day stay.
The jury concluded: “Mr Gunner was found at approximately 2pm on March 26, 2015, in an unconscious state.
“He was in the locked bathroom of dormitory three Clare Ward within the ACU where he had been detained from March 10 under Section 3 of the Mental Health Act following an attempt at self-harm at his residence.
“He had been diagnosed with schizoaffective disorder and exhibited symptoms of depression, anxiety, paranoia and psychotic behaviour.
“He had consistently relayed suicidal ideation to medical staff with the last documents occurrence being on the day of his death. The boot laces used as the ligature had been readily available.”
'Very paranoid'
The 43-year-old was transferred to the Chertsey unit on March 10, 2015, after he was admitted to Royal Surrey County Hospital following an overdose where he took a "large amount of medication" at home.
The jury was told Mr Gunner expressed "ongoing suicidal thoughts" to staff at the unit days and hours before he was found lying unconscious in his bathroom dormitory on March 26, 2015.
Despite attempts by staff and emergency services to revive Mr Gunner, he was pronounced dead at the scene at 2.38pm.
The medical cause of death given was "ligature compression of the neck in association with foreign body airway obstruction".
Dr Jolanta Landowska told the court that she conducted three reviews with Mr Gunner before his death and that he had spoken of having "no future" on the day he died.
She described Mr Gunner as "very paranoid", as he believed builders had planted spy cameras in his house and that the people on television knew "what he was wearing".
'Almost unbelievable'
Speaking after the inquest, sister Jane Fitzsimmons said Mr Gunner was the eldest of four children with two younger brothers.
When he was younger, he enjoyed fishing and camping and liked being outdoors and anything to do with nature.
She said Mr Gunner was an "extremely talented artist" and his drawings were of such quality that he could have sold them if he had wanted to.
Mrs Fitzsimmons said she was concerned about "failings" at the ACU.
“As a family, to lose a loved on through suicide is utterly devastating, but to lose a loved one while entrusted into the care of a muti-professional team is almost unbelievable,” she said.
“Words cannot express our shock, sadness and frustration that Barry succeeded in taking his own life whilst a patient within the ACU.”
'Careful balance'
Andy Erskine, director of mental health and social care at Surrey and Borders Partnership NHS Foundation Trust, said:
“I offer my heartfelt condolences to Mr Gunner’s family and friends.
“We take any death in our services extremely seriously and have completed an internal investigation into Mr Gunner’s care and treatment to make sure we do everything in our power to prevent anything similar happening again.
“As part of our investigations we met with Mr Gunner’s family to make sure we explored their concerns.
"Our findings have also been reviewed by medical professionals who were not involved in his care and treatment to identify further lessons to be learned.
“We have now implemented the recommendations from our investigation across all of our inpatient services.
"These include making sure we search inpatients’ possessions that are brought onto the ward, but kept in storage, making sure we offer people one-to-one time with nurses every day and that we record the outcome of all discussions about medication, even if no changes are made.
“We have to strike a careful balance between protecting people from self-harm with the need to promote people’s recovery from mental ill-health to enable them to return home.
"The coroner recognised that we have thought carefully about this issue in this instance.
“I am very sad this has happened and I am very sorry for the Gunner family’s loss.”
The six-day inquest at Surrey Coroner’s Court into Barry Gunner’s death came to an end on Monday (July 25) when a jury gave a verdict of "suicide".
The jury heard from medical clinicians and nursing staff from the Abraham Cowley Unit (ACU) of St Peter’s Hospital, who looked after and treated Mr Gunner during his 16-day stay.
The jury concluded: “Mr Gunner was found at approximately 2pm on March 26, 2015, in an unconscious state.
“He was in the locked bathroom of dormitory three Clare Ward within the ACU where he had been detained from March 10 under Section 3 of the Mental Health Act following an attempt at self-harm at his residence.
“He had been diagnosed with schizoaffective disorder and exhibited symptoms of depression, anxiety, paranoia and psychotic behaviour.
“He had consistently relayed suicidal ideation to medical staff with the last documents occurrence being on the day of his death. The boot laces used as the ligature had been readily available.”
'Very paranoid'
The 43-year-old was transferred to the Chertsey unit on March 10, 2015, after he was admitted to Royal Surrey County Hospital following an overdose where he took a "large amount of medication" at home.
The jury was told Mr Gunner expressed "ongoing suicidal thoughts" to staff at the unit days and hours before he was found lying unconscious in his bathroom dormitory on March 26, 2015.
Despite attempts by staff and emergency services to revive Mr Gunner, he was pronounced dead at the scene at 2.38pm.
The medical cause of death given was "ligature compression of the neck in association with foreign body airway obstruction".
Dr Jolanta Landowska told the court that she conducted three reviews with Mr Gunner before his death and that he had spoken of having "no future" on the day he died.
She described Mr Gunner as "very paranoid", as he believed builders had planted spy cameras in his house and that the people on television knew "what he was wearing".
'Almost unbelievable'
Speaking after the inquest, sister Jane Fitzsimmons said Mr Gunner was the eldest of four children with two younger brothers.
When he was younger, he enjoyed fishing and camping and liked being outdoors and anything to do with nature.
She said Mr Gunner was an "extremely talented artist" and his drawings were of such quality that he could have sold them if he had wanted to.
Mrs Fitzsimmons said she was concerned about "failings" at the ACU.
“As a family, to lose a loved on through suicide is utterly devastating, but to lose a loved one while entrusted into the care of a muti-professional team is almost unbelievable,” she said.
“Words cannot express our shock, sadness and frustration that Barry succeeded in taking his own life whilst a patient within the ACU.”
'Careful balance'
Andy Erskine, director of mental health and social care at Surrey and Borders Partnership NHS Foundation Trust, said:
“I offer my heartfelt condolences to Mr Gunner’s family and friends.
“We take any death in our services extremely seriously and have completed an internal investigation into Mr Gunner’s care and treatment to make sure we do everything in our power to prevent anything similar happening again.
“As part of our investigations we met with Mr Gunner’s family to make sure we explored their concerns.
"Our findings have also been reviewed by medical professionals who were not involved in his care and treatment to identify further lessons to be learned.
“We have now implemented the recommendations from our investigation across all of our inpatient services.
"These include making sure we search inpatients’ possessions that are brought onto the ward, but kept in storage, making sure we offer people one-to-one time with nurses every day and that we record the outcome of all discussions about medication, even if no changes are made.
“We have to strike a careful balance between protecting people from self-harm with the need to promote people’s recovery from mental ill-health to enable them to return home.
"The coroner recognised that we have thought carefully about this issue in this instance.
“I am very sad this has happened and I am very sorry for the Gunner family’s loss.”
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You can take a look at a selection of previous reports on the unit on the 'Pages' section on the right hand side of this Blog.
Neil Harris
(a don't stop till you drop production)
Home: helpmesortoutstpeters.blogspot.com
Contact me: neilwithpromisestokeep@gmail.com
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