Jason Walker left alone for at least half an hour

THE family of a man who killed himself by slashing his throat with a razor blade while he was a patient in a secure psychiatric unit are still waiting for answers.

Systemic failures among staff and the hospital trust meant Jason Walker’s bloodsoaked body could have lain undetected for hours, a jury at his inquest concluded.

The 34-year-old was found dead in his bed on the Stephenson Ward of the University Hospital of North Tees, in Stockton, just before 7.30am on May 17, 2007.

Despite being on close observations, which meant he was to be checked at tenminute intervals, he was left alone for at least half an hour, so was able to cut his throat and die before being found by hospital staff.

Eugene Carr, who was the ward manager when Mr Walker killed himself, was one of three staff members who were dismissed by Tees, Esk and Wear Valleys NHS Foundation Trust following his death.

Speaking after the hearing, Jason’s sister, Vanessa Brigham, said: “We are deeply disappointed that after all this time we still don’t have any real answers to how Jason was allowed to die. Jason was extremely vulnerable and they knew this, but still they failed on so many levels to protect him. We feel overwhelmingly let down.”

A narrative verdict written by the jurors identified a raft of systemic failings including: ● Information was not passed to staff on the unit relating to his state of mind; ● Mr Walker was not given sufficient one-to-one sessions during his stay; ● His named nurse did not have a one-to-one session with him during his stay; ● Observations records were not filled in sufficiently and there periods where no observations were taken at all; ● There was no interaction between night shift staff from 9.30pm until he was discovered dead; ● No systems were in place for the management of razors; ● There was no risk assessment carried out after Mr Walker failed to take his medication the evening before he was found dead.

Deputy Teesside Coroner Tony Eastwood recorded that Mr Walker killed himself while the balance of his mind was disturbed.

Beth Reay, of Irwin Mitchell solicitors, who represented Mr Walker’s family, said: “Of most concern to Jason’s family are the very serious problems with the systems of observation, risk assessment and management of harmful objects on the ward.

“It is unfortunately clear that observation charts were falsified, medication charts were incorrectly filled in and crucial opportunities for therapeutic engagement with Jason were missed during the final days of his life.”

Martin Barkley, chief executive of Tees, Esk and Wear Valleys NHS Foundation Trust, said: “Mr Walker was undoubtedly let down by the trust and by some of the people who were there to care for him.

“Some of the staff did not follow procedures and he did not receive the level of care that we would expect to see.

“We undertook our own investigation and this resulted in a number of actions, including changes on the ward.”