Deaths at the Abraham Cowley Unit, St. Peter's Hospital, Chertsey.

Wednesday, 25 February 2015

Deaths at the Abraham Cowley Unit at St. Peter's Hospital, Chertsey.

Ashford and St. Peter’s NHS Foundation Trust takes up a lot of my time; you wouldn’t think I’d want to take on any more. You would be right.

However there is another scandal in the grounds of St. Peter’s Hospital, Chertsey although it doesn’t involve the Trust.

The Abraham Cowley Unit is a complex run by ‘The Surrey and Borders Partnership NHS Foundation Trust’ which treats mentally ill people including those detained for their own safety under the Mental Health Acts. Patients there are normal people suffering from illnesses that require monitoring and management. Some of them need to be held in a secure environment for a time.

Most patients live normal lives but may need to stay as inpatients every so often. At those times, the hospital should be caring for them and providing them with a place of safety until they are well enough to leave.

No one wants a return to the days when such places were frightening gothic prisons and yet; a place of safety needs to be safe.

The Abraham Cowley Unit is not safe.

I visited the Unit a number of times in the 2000’s, visiting clients (when I was working). I also visited many other similar units and was often surprised by how poor the supervision and security was.

These inquest reports confirm that the Unit has been failing for a number of years.

The recent inquest of Simon Tree has resulted in The Coroner issuing a legally binding notice under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Notices like this are made to trusts where unsafe practices have resulted in a death and where a Coroner has identified unsafe practices which are like to result in further similar deaths, if nothing is done. It requires the Trust to respond to the Coroner about how it intends to avoid similar deaths in future.

The evidence given by staff is not what it should be;


Paranoid schizophrenic Simon Tree had threatened to jump in river two days before death, inquest hears;


 Get Surrey   

 23 January 2015 

 By Matt Strudwick


A coroner said he would be issuing a prevention of future death report to a mental health unit after four subsequent patients also absconded.


Simon Tree went missing from a mental health unit before drowning in the River Thames.


A man with paranoid schizophrenia threatened to "jump into a river" just two days before his body was found in the Thames, an inquest has heard. Simon Tree, 49 - formerly known as Gary Randall - was found dead by a canoeist near homes at Sunbury Court Island on February 18 2012.


A five-day inquest held at the coroner’s court in Woking this week was told Mr Tree was having treatment in the Abraham Cowley Unit (ACU), based at St Peter’s Hospital in Chertsey.


He was there voluntarily after setting fire to his Stanwell home in a failed suicide attempt a month earlier.


Mr Tree, who was diagnosed with depression at the age of 18, had been taken back to the unit by police on the evening of February 16, after he was found drunk and walking towards the river by a couple in Thames Street, Sunbury.


He had been reported missing by the ACU at 4.38pm.

PC Claire Phillips told the inquest how, when she and two colleagues returned him to the Blake Ward at the ACU, she felt charge nurse Stephen Livesley had not taken the situation seriously enough.


“I stated Simon said he wanted to jump into the river and, I wouldn’t say he was dismissive, but he said ‘they always say that when they’re drunk, it’ll be different in the morning’,” she said.


“I didn’t challenge the comment, but was surprised because he was so blasé about it.”


'High risk'


Mr Livesley said he had no recollection of the conversation, but had told colleagues Mr Tree should be reassessed the next morning by doctors when he had sobered up.


“It was the first I heard in terms of Simon wanting to put himself into a river,” he told the inquest. “First I knew Simon had any attempt to take his own life or may have had.”


The inquest heard Mr Tree was allowed off the ward by nurse Steven Hope at 8.20am the following morning, onto the main corridor for breakfast, where patients could gain access to the delivery area.


Mr Livesley said the area was used as the main entrance at the time, due to maintenance work at the front entrance, and the door was "insecure" and had "occasionally not closed fully".

At around midday, staff nurse Cecil Nhlangano raised the alarm that Mr Tree was missing after colleagues could not find him in the facility for an assessment.


It took staff until 7.40pm to report him missing to the police as they had thought he may have gone shopping.


“I disclosed with the ward manager, also, to try to come up with a plan,” said Mr Nhlangano.“What we concluded was to give him a chance to come back as he might have gone shopping.


“Those were some of the reasons as he had requested to do some shopping for clothes [earlier in the week].”


Coroner Simon Wickens asked why the "intervening event" [of Mr Tree being found drunk near the river] had not come into the discussions.


“You knew this issue where he was going to take his own life and you knew he had gone missing from the ward,” he said.

“At midday, is he not, in your mind, a high risk, given those events?”

But Mr Nhlangano said the risk had been minimised due to his return to the ward and him no longer being intoxicated.


Mr Tree was not found until 5pm the following day, when firefighters pulled his body out of the river.


His father, William Randall, said; “At Christmas 2011, he said he felt like jumping off Staines Bridge but had shuddered at the thought of it. “The last time I saw, Simon was on Blake Ward on February 15, when I brought him in some more socks.”


A post-mortem examination concluded he had died from drowning, with toxicology results showing small traces of prescribed drugs Citalopram and Risperidone, which were being used to treat his depression and schizophrenia.


Giving a narrative verdict on Friday morning, Mr Wickens said he would be issuing a prevention of future death report to the unit after four subsequent patients absconded in the past year - "four too many", as he described it.


"In one incident the camera covering the air lock was moved to a blind spot to assist a patient to leave," he said.


"I propose to make a prevention of death report to the unit to take steps to address those issues and closer monitoring of those exiting the building."

I’m not surprised that the Coroner was angry about the four recent absconders from the Unit but the situation was worse than that.

This next report is again from ‘Get Surrey’ and it concerns another recent inquest which also deals with a death from 2012 (why does it take so long?).

This is negligence plain and simple. There was no assessment of her mental state on her return to hospital and how on earth did she get hold of a knife in a place of safety?;


Mental health unit failings contributed to Katherine Bonaventura death, inquest jury decides.


Get Surrey.

14 January 2015 

By Becca Taylor


The 28-year-old, who was a diagnosed schizophrenic, stabbed herself in the chest but an inquest jury said there was not enough evidence to establish if she had intended to cause her death. Failings in procedure at a mental health unit in Chertsey "more than minimally" contributed to the death of a promising musician from Godalming, an inquest jury has ruled.


Katherine Bonaventura, who lived in Warramill Road, died in December 2012 from a haemorrhage after a stab wound to the chest, sustained while she was a detained patient in the Abraham Cowley unit based at St Peter's Hospital.


Miss Bonaventura had returned to the unit following overnight leave with her mother Patricia on December 7 2012.


She returned just after 11am and her registered clinician Dr Sheetal Sirohi had plans to see her for an assessment at around 2pm that same day.


Miss Bonaventura was found in a corridor at the unit shortly after 2pm, with a knife in her chest.


Paramedics attended and she was transferred to the trauma unit at St Peter’s, but was pronounced dead at 4.22pm. She was 28-years-old.


A jury at the inquest ruled she died as a result of her own actions, but that there was not enough evidence to establish whether she had intended to cause her death.


The jury also ruled that the unit had failed to elicit information when Miss Bonaventura returned that day, and that they failed to "sufficiently and immediately" assess her mental state.


'I'm going to hell'


Miss Bonaventura was diagnosed with schizophrenia in 2009, and over the following four years had various periods in hospital, both voluntarily and under section three of the Mental Health Act.


The night before her death, Miss Bonaventura had been celebrating her mother’s birthday at a restaurant with friends.


Mrs Bonaventura said she had tried to express concerns to staff at the ward when they returned that her daughter had been drinking heavily, which was at odds with the anti-psychotic medication she was on, but that she felt the concerns were dismissed.


Giving his evidence, Sunil Boo Jharut, charge nurse at the unit, said he had no recollection of Mrs Bonaventura expressing any concerns about the leave, and that no formal note had been made of any handover.


After the alarm was raised, Dr Sirohi cradled Miss Bonaventura as she lost consciousness.


Her last words were "I’m so sorry. I’m going to hell. Let me go".


Staff said Miss Bonaventura’s presentation seemed to be improving, though her mother said that just two days before she was granted the overnight leave there had been concerns she was having suicidal thoughts.


'Sad incident'


Assistant coroner Alison Hewitt confirmed that she had it in mind to write a report, or a letter, to the Surrey and Borders Partnership NHS Foundation Trust (SABP), which runs the Abraham Cowley unit, to make her suggestions as to improvements that could be made following the jury’s verdict.


Jo Young, director of quality at SABP, said: “We extend our heartfelt and sincere condolences to Miss Bonaventura’s family for their sad loss.


“Maintaining the safety of people who use our services is a vital part of our work, and across the organisation we are embedding all that we’ve learnt from this sad incident.


“Recommendations were made as a result of our internal review and these are being fulfilled to ensure we improve our practices.


"These have included clearer guidance for staff in relation to searching a person, their rooms and personal belongings, more detailed risk management plans, staff documenting feedback from carers, family, friends when a person returns from leave, and managing any identified risks appropriately.”

I’m very concerned that for the second time staff had no recollection of what happened and there appear to be no written records of what happened.

It’s a shame that a different coroner was dealing with this inquest; a combined report would have been better.

This next article (also from ‘Get Surrey’) last year was meant to be reassuring but it isn’t. It was written after the two deaths in 2012 but before the inquest’s this year.

You would think there were no problems;


Security levels improving at the Abraham Cowley Unit

Get Surrey

3 May 2014 

By Russell Butt


The director of mental health services at the Surrey and Borders Partnership NHS Foundation Trust has said the numbers of patients wandering off at the ACU has steadily reduced.


Security levels at a mental health unit in Chertsey are said to be improving, despite two worrying incidents in April.

The Abraham Cowley Unit (ACU), based in the grounds of St Peter's Hospital, has had issues in the past with patients going missing, although most return unharmed.

In one recent incident a patient was talked down from a bridge over the M25 in Green Lane, Chertsey, by a passer-by. Just two days later, another patient was coaxed down from a roof of in the hospital grounds, prompting concerns over security at the unit.


However, Andy Erskine, director of mental health services at the Surrey and Borders Partnership NHS Foundation Trust, which runs the ACU, said that despite these two incidents, the numbers of patients wandering off had steadily reduced during the past three years, even though more people were using the service.


He said: "With four wards for people with acute mental ill-health, the Abraham Cowley Unit in Chertsey is our largest in-patient site in the county.


"Our first priority is to keep people safe while they are with us and we are continually reviewing and improving the way we work.


"The number of people going AWOL (absent without leave) across our inpatient services, and especially at the ACU, has dropped significantly in recent years.

In 2009-10 the number of AWOLs from the ACU was 80, in 2011-12 it was 48 and in 2012-13 it was 10."


Mr Erskine said the overall AWOL figure for the trust as a whole was 43 for 2012-13.


He added: "This is a real success considering that more people than ever are staying at the ACU since a new ward opened in 2012. This reflects a concerted effort from us to improve security levels.


"We have invested in improvements such as secure card entry doors, as well as giving patients more opportunities to talk about their feelings so people understand why they should remain in our care.


"Some people are able to leave to see family or friends as part of their recovery and if they are late returning, then this has to be logged as an AWOL.

We would not expect a zero rate of AWOLs, although we are, of course, determined to keep this to a minimum to protect patient safety as much as possible.


"This means that if people are AWOL, we review what happened and try to improve our services."

The problem? We know from the Coroner that as of this year it is still a problem and in 2014 there were two very serious incidents that resulted in this rather complacent interview.

More worrying is that the Trust seems to think that 2012 (with only 10 absconders) was a good year; one of them died.

I’ll be watching Abraham Cowley closely from now on to see how many more incidents happen!

Neil Harris

(a don’t stop till you drop production)

Contact me;

It's taken me a while to find this report on yet another inquest into a tragic death at The Abraham Cowley Unit which shares the St. Peter's Hospital site at Chertsey.

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;

'Talented artist' from Godalming took his own life while in hospital, inquest jury concludes

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.”


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