Errors evident as Article 2 Inquest concludes

In late June 2019, after disclosing that he thought daily about killing himself, in addition to suffering from delusions, Mr Bird had been detained at the hospital under Section 2 of the Mental Health Act. Initially, medical teams at Hafan y Coed checked in with Robert every 15 minutes, but following a ward transfer, observations were reduced to just once-per-hour.

On 8^th July 2019, Robert was discovered with a ligature around his neck, from an item that he should not have had access to. Although a pulse was found, he was unresponsive and unable to breathe without assistance. On 9^th July, Robert was transferred to the Intensive Care Unit at University Hospital Wales and an examination confirmed that Mr Bird was ‘brain stem dead’. Robert subsequently died on 14^th July 2019.

The jury concluded that errors were indeed made in the risk assessment documentation, meaning the wrong level of observations were in place when Robert was able to take his own life. Recommendations were also made to the locking system used by Hafan y Coed Hospital, as well as to the supervision policy in areas such as the laundry room. However, the jury were unable to ‘definitely determine’ how Mr Bird obtained the plastic bag.

Craig Court, Partner and head of the Actions Against Public Authorities team commented:

This is a disappointing conclusion. A series of mistakes meant that Robert was able to take his own life within a facility that his family trusted to keep him safe.

However, I hope that the findings from this inquest facilitate a process of learning and improvement to ensure that others are not failed in the same way that Robert was. We are yet to fully witness the impact of the pandemic on already overstretched mental health services – we must ensure that the care provided to the most vulnerable members in our communities is sufficient in ensuring the avoidance of further deaths.

Thanks must go to the team at Harding Evans, who have worked tirelessly in the lead up to this inquest, as well as David Hughes of 30 Park Place Chambers for representing the family at the hearing.

I would also like to extend my thoughts to Robert’s family, whom we have worked closely with and have displayed incredible strength during this difficult process.

A member of Robert’s family stated:

Despite the fact that the inquest has concluded, we have been left with so many unanswered questions regarding how our son tragically died. Despite the evident suicide risk he presented, what seems like counterintuitive actions were taken, with Robert’s observations reduced. Above all, we are still questioning the events that meant he was able to access items that led to his untimely death – how could this have happened in a place that was meant to keep him safe?

The Actions Against Public Authorities team at Harding Evans has been recognised as ‘one of the leading public sector claimant practices in Wales’, with head of department Craig Court listed as a ‘Rising Star’ in the recent Legal 500 rankings and ‘Associate to Watch’ in Chambers UK.