Portsmouth coroner says man found dead in grounds of St James’ Hospital had clearly been in turmoil

Stephen Hipkins
Stephen Hipkins
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A CORONER has recorded a narrative verdict after a mental health patient was found hanged inside the grounds of a hospital.

Stephen Hipkins, 28, was discovered dead at St James’ Hospital in Portsmouth on January 27 last year, despite a locked-door policy being in place.

He had been a voluntary patient in the Hawthorn ward of The Orchards.

At an inquest held at the Portsmouth Guildhall yesterday, coroner David Horsley said Mr Hipkins suffered from mental health problems for a number of years, drinking problems and self-harm issues.

But Mr Horsley said that Mr Hipkins genuinely wanted help and was a patient at St James’ Hospital on a voluntary basis.

Mr Horsley said: ‘It was clear there was a lot of turmoil going through his mind.

‘How he left that ward on that night we simply don’t know – there are a number of possibilities. He could have been let out by someone who had a key, he could have tailgated someone, or got someone to let him out the back garden and get over the very low fence. What he did was very dangerous and led to his death.

‘We can’t say 100 per cent that he wanted to take his own life, so I will record a verdict of a short narrative.’

Mr Hipkins had been living in Great Yarmouth for about four-and-a-half years, but came back to Portsmouth in December 2012 to escape an abusive relationship.

On January 21, 2013, Mr Hipkins went to Queen Alexandra Hospital after drinking a litre of vodka and having superficial cuts to his arms.

He became a voluntary patient under the care of Solent NHS Trust, which runs The Orchards, on January 22, last year.

The court heard that Dr Ahmad Hadi, a locum consultant psychiatrist, carried out a medical assessment in which he did not think Mr Hipkins was at risk of harming himself.

Dr Hadi said that Mr Hipkins would be entitled to leave, but at this point Mr Hipkins became upset and left the room, thinking he was being discharged.

He went to the Hanway Medical Practice, in Hanway Road, Buckland, to register as a patient in Portsmouth, as he feared he would be sent back to Great Yarmouth.

There he spoke with Dr Shane Lookit. He told the inquest: ‘Stephen said he felt like he was going to hang himself if he did not get any help.

‘He had not picked a place, but I felt this wasn’t improbable so I called the Crisis team.

‘They said Stephen had not been discharged, but was allowed to get leave.

‘I said it would be a good idea for him to return and he agreed.’

After returning to The Orchards, nursing staff said that while Mr Hipkins did not interact with staff much, he was social with patients and, in particular, one female.

On January 27, Mr Hipkins was seen in his room during hourly observations at 7pm. But at the 8pm ward round, he was not in his room.

After a ward search was conducted, nursing staff alerted security about a missing patient.

At 10pm Mr Hipkins was found hanging in the grounds of St James’ Hospital.

The court heard security measures had not been in place fully.

Speaking after the inquest, Mr Hipkins’ mum, Tina McNair said: ‘I don’t want any family to go through what we have been.’

A SECURITY report commissioned by Solent NHS Trust found there was a lack of security in The Orchards.

The report was undertaken after 28-year-old Stephen Hipkins was found hanged in the grounds of St James’ Hospital, on January 27, last year.

The report found that a key management system, which had been installed in 2004 when the site opened, had not been used to its maximum capacity.

Key fobs that were carried by nursing and domestic staff were not individual to its owner, and there was no computer system to log which fob was used to open a door.

It also found a lack of CCTV in areas directly outside the ward, so staff would not be able to tell which direction a patient went upon leaving. And a fence in the garden on the ward measured only 1.8 metres in height.

Since Mr Hipkins’ death, the trust said it has made changes.

Matthew Hall, Solent’s operations director for adult mental health, said: ‘Following a review we have had the key management system reprogrammed, so it is now used to its full potential.

‘Each fob key has been given to an individual – keys used to be issued generically.’

Other changes include installing CCTV cameras near the entrance of the ward.

And the garden fence has been replaced by a 3.6m fence, with all moveable objects taken away, so no-one is able to climb on top and jump over the fence.