Leicester coroner blames suicide on catalogue of failures
The death of a Leicestershire man who hanged himself at a mental health unit was the result of a "catalogue of failures", an inquest heard.
Michael Coltman, 48, died at Bradgate Unit located at Glenfield Hospital after hanging himself with a sheet.
Leicester coroner Catherine Mason said bedding was originally taken away after a first suicide attempt but returned by staff who had not been briefed.
Leicestershire Partnership NHS Trust accepted mistakes had been made.
The case has been referred to the Care Quality Commission for investigation.
Mrs Mason said paperwork on Mr Coltman, from Glen Parva, who suffered from schizophrenia, was not completed properly and it was unclear how often he was observed at the health unit.
She said the staff seemed to treat the recommended 15-minute observation checks as "tick-box exercises".
Mr Coltman, who was admitted to the hospital after driving a car into a wall, told the nursing staff that he wanted "to end it all" but this was not reported to his doctor.
He tried unsuccessfully to hang himself with a sheet on 13 January and was found dead in his room the next day.
Mrs Mason said: "It is one thing to accept that risks cannot be entirely removed, but it beggars belief that through poor documentation and communication, Mr Coltman was given the very tool he used to take his own life.
"There was a missed opportunity for medical review and therefore no certainty that Mr Coltman's care was in accordance with his needs at the time of his death.
"It is clear to me that there has been a catalogue of failures stemming from an institutional complacency."
Mr Coltman's sister Pauline Caney said after the inquest: "Information was not passed on correctly to the right people.
"There was one nurse who gave him the sheet on the day he died - and he had tried to take his life the day before - and if she had known about that incident then I am sure he wouldn't have been given that sheet."
John Short, chief executive of Leicestershire Partnership NHS Trust, said: "We wholly regret Mr Coltman's death and know the family continue to be affected by this tragedy and our sympathies are with them at this difficult time."
He said an internal investigation prior to the inquest had found "failures in Mr Coltman's care", particularly in regard to communication and record keeping.
The inquest was delayed for several days while the Crown Prosecution Service considered whether any criminal charges would be filed.
It was decided that no further legal action would be taken.