MENTAL health chiefs have come under fire again after the daughter of a man who fell to his death from a car park said: ‘His death could have been prevented.’
It comes as Flick Drummond, Portsmouth South MP vowed to look into mental health care in the city and called for people facing problems to contact her.
Mark Talbot died after suffering multiple injuries when he fell from the top floor of the multi-storey car park at Tesco in Crasswell Street, Portsmouth, just hours after his family told a crisis team he was suffering from psychotic hallucinations.
Solent NHS Trust bosses carried out a review and promised to make changes.
Another trust, Southern Health, vowed to change its mental health services after the deaths of Mark O’Shaughnessy, 28, of Williams Close, Gosport, and Craig Greer, a 33-year-old dad, of Woodcot Crescent, Havant.
Southern Health NHS Foundation Trust said more should have been done to help the men.
And just last week the same trust said it will learn lessons from the death of David Hinks, 30, from Havant, who killed himself after telling medics he wanted to do so.
An inquest in Portsmouth yesterday heard CCTV recorded Mark in the car park stairwell at 5.48am but minutes later he was found in the street by Royal Mail worker Nathan Brennan.
He called 999 and gave CPR but Mark was declared dead by paramedics at 6.14am.
The inquest was told the 49-year-old artist had a ‘complex’ and ‘challenging’ case of bipolar affective disorder and had previously overdosed.
His mother Lesley Talbot, 71, and his four children Lucy, 28, Tara, 24, Lily, 19 and Charlie, 18, heard from a consultant that his care ‘could have been better’ and his death sparked a review at Solent NHS.
The inquest heard Mark, who had previously wanted gender reassignment, had been in and out of St James’ Hospital.
His care co-ordinator changed in the lead up to his death on October 3 and the replacement went off sick, leaving him being looked after by an intensive care management team and seen by different medics each time.
His daughter Lucy spoke to the crisis team the night before his death and told them he was suffering psychosis.
He believed he was going to jail for benefit fraud as the Department for Work & Pensions had sent him a letter about changes to the type of benefits he was receiving.
The crisis team made an appointment for 11am on October 3 – the day of his death.
Lucy said: ‘I took that as reassurance from professionals that dad would be okay until 11am.’
But Katie Tapp, a crisis team health practitioner, told the family: ‘We’re really sorry for the loss because we didn’t really see that outcome otherwise possibly we could have got the night staff to see him.’
Lucy told the coroner’s court she believes her dad should have been detained in hospital.
He had been at St James’ Hospital hospital several times before he died and was briefly sectioned but discharged.
Dr Kayode Osanaiye, a consultant in adult mental health, told the family his report found ‘there was no reason to keep him in hospital’.
Assistant coroner Robert Stone recorded an open conclusion into Mark’s death.
Speaking to The News after the inquest, Lucy said: ‘I believe he should have been kept in hospital. The crisis team should have come out to see him that evening and I believe they should’ve taken our concerns more seriously.
‘Every person is different but people are slipping through.’
She added: ‘His death could have been prevented, and hopefully now it will prevent future deaths.
‘I feel relieved and I’m hoping that the outcome we got is going to make a difference to other families.’
At Portsmouth Coroner’s Court, Dr Osanaiye detailed several findings in his report following Mark’s death.
These related to handovers by care co-ordinators, better understanding of symptoms and the criteria of admissions.
Solent NHS Trust will now make changes in four areas:
n Review of current admission criteria.
n Developing clear guidelines for unregistered health professionals and their accountability in decision-making.
n Changes of care co-ordinator will be managed better in complex cases, notifying the patient as soon as possible.
n Greater awareness and support for family in unexpected deaths.
Paying tribute to her dad, Lucy added: ‘He was amazing, he was my best friend as well as my dad.
‘I felt I knew him so well, that’s why I wanted to get justice not to get a suicide verdict.’
Mr Stone said he recorded an open conclusion instead of suicide after hearing Mark was scared of heights and that he may not have been able to form the intention to kill himself.
He told the family the death was ‘not an accident’ and Detective Constable Jim Wells said no third party was involved.
Mandy Rayani, chief nurse at Solent NHS Trust, said: ‘I would like to extend my sincere condolences to Mr Talbot’s family and friends.
‘His death while in our care was unexpected and in our evidence to the coroner today we outlined some of the steps we are taking to review processes identified in our internal investigations following Mr Talbot’s death.’
She added: ‘We would also welcome an opportunity to meet with the family to discuss our final report and actions identified.’