Man cut off hand after trusts 'missed opportunities' to help him
PUBLISHED: 12:00 11 June 2015
A man deliberately killed himself after cutting off his hand with a hacksaw, although more could have been done to prevent his death a coroner has concluded.
Nicholas Sims was found dead at his Long Ashton home after the North Bristol crisis team turned up late to assess his mental health.
At an inquest into his death on June 2, Flax Bourton Coroner’s Court was told the 63-year-old had been diagnosed with psychosis and had repeatedly visited his doctor complaining about tinnitus and worrying his pacemaker was being controlled by outside forces.
On October 13, Mr Sims called an ambulance after taking an overdose and cutting his wrist. He was admitted to the Bristol Royal Infirmary (BRI).
Mr Sims was seen by clinical nurse specialist, Holly Starkey.
She said: “He had taken tablets because he was feeling very anxious because he had ringing in his ears and he couldn’t sleep. He said he couldn’t cope with it any longer.
“He said he felt anxious about going home and asked to stay in the BRI overnight.”
She believed Mr Sims could be treated at home by the North Bristol crisis team based at Weston’s Long Fox Unit, but asked a member of staff to visit that night because he was a ‘significant risk’.
He was sent home at 8.15pm in a taxi. Dominic Jefferies from the crisis team was sent to visit Mr Sims that night.
Mr Jefferies said: “I wasn’t aware of there being any particular risk, but I knew there was some concern.
“His assumption was that I’d arrived to take him to hospital.
“I explained I’d come to see how he was and see what support could be offered and told him he would be assessed the following day.”
Community psychiatric nurse Jeremy Darby, from the crisis team, explained Mr Sims’ was not seen in the morning as the doctor was unavailable until the afternoon.
Mr Darby called Mr Sims at 1pm to arrange an appointment and went to his home at 7.45pm when he had no response.
He called the police to carry out a welfare check and officers found Mr Sims dead on the kitchen floor.
Senior coroner Maria Voisin said a review into Mr Sims’ death by United Bristol Hospital Trust and Avon and Wiltshire Mental Health Trust had raised concerns because he was not seen at home for 20 hours and ‘the delay may have resulted in potential suicide prevention opportunities having been missed’.
The coroner recorded a narrative conclusion. She said: “Mr Sims had attempted to take his own life by taking an overdose.
“He had been discharged from the BRI on October 13 and into the care of the crisis team.
“He was not assessed for hospital admission that night. I consider this to have been a missed opportunity to provide medical care or treatment.
“Mr Sims was found at his home address that day. He had cut off his own hand with the intention of taking his own life. He died from a self-inflicted injury.”
The coroner said both trusts had been thorough in implementing changes since Mr Sims’ death and considered all matters had been addressed.