IMPROVEMENTS have had to be made at Queen Alexandra Hospital following the death of a man who jumped into the path of a train.
Steven Murphy was killed instantly at Liss railway station when he jumped from a bridge.
Just a couple of hours before, the 41-year-old had been at QA in Cosham and had been let out for a cigarette break.
An inquest at Portsmouth Coroner’s Court heard Steven was admitted to the hospital on June 5 – the day before the train tragedy – after taking an overdose of painkillers.
Doctors instructed he was to be escorted by security because of concerns about his mental state.
But, on the morning of June 6 last year, Steven was allowed to go on several cigarette breaks without security as staff said he always returned.
But at lunchtime that day, Steven got a taxi to Liss station, close to where he lives, and jumped from the bridge shouting ‘sorry’, the inquest was told.
The incident sparked an investigation at the hospital and since then risk assessments and mental ‘capacity’ assessments for patients in acute medical care are now formally documented.
The inquest heard Steven’s mum Sandra Murphy was contacted by hospital staff at about 1pm after he had not returned from a cigarette break.
Sandra rang her son, who said he had taken a taxi home.
Sandra drove to Liss and passed several emergency vehicles making their way to the railway station, the inquest was told.
Sandra told the coroner: ‘There was a commotion.
‘I walked across and there was an ambulance woman walking towards me.
‘I never even gave Steven a thought. I said “I hope you haven’t got my son in that ambulance”. I was kidding.’
Hearing evidence from the hospital, Benjamin Downer, a trainee advanced clinical practitioner, told the inquest Steven had taken an overdose the day.
When asked by Steven’s family why the mental health team were not involved, he said his first priority was to treat the overdose.
The next morning, Steven was seen by Dr Michael Bacon and a junior doctor, who carried out a formal mental capacity assessment, but it was not formally documented.
Steven’s family told the team ‘he should not have been able to go out on his own’.
Mr Bacon said: ‘The assessment that morning was that he was probably okay to go out and come back.’
Dr Simon Hunter, a consultant in accident and emergency, said an investigation was carried out to see if ‘any lessons could be learned’.
He said the accident and emergency unit had to be ‘much more formal’ in the way things are documented, including vulnerable people being allowed to leave for breaks. ‘We need to formalise how we document capacity assessments,’ he said.
‘It was not done. There is now a form where we can formally document it.’
He said there are now formal forms to be filled in for patient risk assessments across the acute medical departments.
Coroner David Horsley concluded Steven took his own life while suffering from severe long-term mental health problems.
He will write to the rail authorities, asking that measures are put in place to discourage people climbing over railway bridges.
After the inquest, Sandra told The News: ‘They should never have let him out on his own. I have lost a part of my heart. All he wanted was a family and a wife, but he just never found anybody.’
A charity event took place in memory of Steven and raised £500 for the charity Mind.