‘Michael shouldn’t have been allowed to go out that night’

INQUEST Michael Carroll
INQUEST Michael Carroll
Swansea City Centre. Credit: Wiki Commons (Labelled for reuse)

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A FAMILY have criticised health officials following the death of a man who overdosed after being allowed out of a psychiatric ward.

Relatives believe Michael Carroll, 28, who suffered from dual diagnosis as a drug addict and schizophrenic, might still be alive had he not been given permission to go out of St James’s Hospital in Milton alone.

An independent report into circumstances surrounding Mr Carroll’s death made 14 recommendations to Solent NHS Trust which runs St James’s Hospital.

These included reviewing the strategy for patients with a dual diagnosis, the missing persons policy, emergency contingency plans, its leave risk assessment form and how care plans are recorded.

Mum Sue Carroll, 55, of The Drive, Emsworth, said: ‘They didn’t take into account the whole situation. They said they did, but they didn’t, otherwise he wouldn’t have died. He shouldn’t have been allowed out that night.’

A Portsmouth inquest heard Mr Carroll was sectioned on a secure psychiatric intensive care unit when he died.

Medics banned him from taking unescorted leave a week earlier after he tested positive for cannabis. But the privilege was reinstated two days before Mr Carroll’s death following a review.

A day later his request for an hour’s unescorted leave was granted following a risk assessment.

Mr Carroll left Maples unit in a taxi at about 7pm, but failed to return an hour later as agreed.

A deputy ward manager spoke to him on his mobile at 8.45pm when Mr Carroll agreed to go back to the unit. But he did not return.

Staff alerted police shortly after midnight on January 22, 2010.

A dog walker discovered Mr Carroll’s body in the grounds of St James’s Hospital the next morning – 13 hours after he left.

A post mortem revealed he died of heroin intoxication.

A jury returned a verdict of accidental death.

Mrs Carroll said: ‘Michael was a vulnerable adult.

‘He was sectioned for his own safety, he wasn’t able to make rational decisions.

‘Certainly he shouldn’t have been allowed out after dark

‘I know Michael’s brother and sister certainly don’t accept the findings.

‘They feel very angry about it, let down and sad. I just feel frustrated.

‘I believe very strongly that it was a mistake.’

David Sellers, author of the report into Mr Carroll’s death, found he was receiving ‘safe and secure’ treatment at the time of his tragic death.

He wrote: ‘He probably stood a better chance on his road to recovery than he had in previous times.

‘It is sad that this incident had such a tragic outcome for him and his family at this potentially promising time.’

Judy Hillier, Solent NHS Trust’s director of nursing and quality, said: ‘On behalf of Solent NHS Trust, I would like to express sincere condolences and sympathy to Mr Carroll’s family.

‘The death of a loved one is a cause of great sadness in any circumstance.

‘We are a caring organisation that looks to provide patient-centred and quality care for anyone who uses our services.

‘Solent NHS Trust takes any case extremely seriously to see if there are lessons to be learned, and has done so on this occasion.

‘We will also be reflecting on the coroner’s court verdict.

‘We have fully co-operated with the coroner and will not be making any further public comment on this matter.’

Changes in care of ‘dual diagnosis’ patients

SUE Carroll praised health officials for steps to improve care for patients with both mental health and substance misuse problems.

But she believes more needs to be done. Mrs Carroll said: ‘We welcome the changes they have made to the dual diagnosis strategy, it will make a lot of difference for a lot of people. They haven’t helped Michael but it’s really good to have them. But I don’t think they have made adequate changes to the risk assessment process.’

Solent NHS Trust which runs St James’s Hospital , Milton, where Michael was sectioned has introduced a raft of steps since his death.

They include three monthly reviews for dual diagnosis patients, an electronic records system and learning groups for substance misuse and mental health staff. A rapid re-referral scheme where known service users ready for discharge can be instantly re-referred if signs of relapse are present is being piloted. The leave risk assessment form, missing persons and other policies have been reviewed.