Neglect by hospital staff contributed to the death of a detained patient in a Darlington hospital, an inquest jury has concluded.

Matthew Gale, 37, died on the train tracks on Mothers’ Day last year. At the time, he was an inpatient at West Park Hospital sectioned under the Mental Health Act.

An inquest at Crook Coroners’ Court heard that staff at West Park filled out the wrong forms, failed to tell Matthew’s mother, Sue Gale, that she must stay with him at all times whilst he was on leave, and did not notice he was missing for nearly two hours the day that he died.

The jury unanimously concluded that neglect by hospital staff contributed to his death. They also told the court that the trust’s failure to tell Mrs Gale about the conditions of Matthew’s leave contributed to his death.

Jurors found that West Park Hospital, run by Tees, Esk and Wear Valleys trust, failed to follow its own policy.

The jury foreman told the court: “Matthew's death occurred on March 19, 2023. Matthew had a history of mental ill health, involving periods as a patient at West Park Hospital in Darlington.

“He intended to take his own life and he did so. Trust policy was not followed, including the forms that were filled out, and not contacting the family about the salient issue of section 17 leave.

“The failure to contact the family contributed to Matthew’s death. Hospital policy had not been followed in regard to his leave. This allowed him to take his own life.

“His death was contributed to by neglect.”

In this context, neglect constitutes "a gross failure to provide basic medical attention to someone in a dependent position.”

On the day he died, Matthew failed to return to the hospital after a period of leave, where he’d been for a Sunday dinner with Mrs Gale to celebrate Mother’s Day.

Despite leave conditions stating he had to be accompanied at all times, his mother was unaware of this, and when Matthew requested he was dropped at his Darlington flat she did not think twice about it.

When asked if she had been told about the conditions to Matthew’s leave, Mrs Gale said: “Absolutely not. Do you think as a mother if someone had explained that he was at a high suicide risk that I would have let him out of my sight?”

But Sue realised something was wrong when she was driving back over to pick him up again – saying: “It was a feeling I’d never felt before, I knew he had gone to take his own life.”

At 6pm, when she discovered he was no longer at his flat, she alerted the police of her worries, and later, at 6.40pm, phoned staff on the ward.

Alison McIntyre, associate director of nursing quality at TEWV, said that Matthew’s absence should have been picked up on a nurse round, scheduled to happen between 5pm and 5.30pm.

But evidence heard by the court showed nurses on Matthew’s ward did not know he was missing until phoned by Matthew’s mother.  

Sadly, the British Transport Police had already logged the incident that killed Matthew. He died at 5.53pm.

The barrister for the trust, Gina Wells, said: “The Trust accepts communication could’ve been better with Matthew’s mother.”

The court heard that this contravened TEWV’s own policy, and good practice guidelines on family involvement in Section 17 leave for patient safety.

Yesterday (Tuesday, May 21), at Crook Coroner’s Court, it emerged that Matthew’s consultant psychiatrist, Dr Ibrahim Jawad, filled out an outdated form when granting Matthew his leave, and that medical records lacked note of any conversations had with Matthew’s family about leave.

Trust witness Alison McIntyre, associate director of nursing, admitted that the trust would “have to take the understanding that if something was not recorded, it did not happen.”

Matthew’s family paid tribute to their beloved son and brother. Mrs Gale said: “He had an ability to make you feel special, and no matter who you were, once you met him you never forgot him.

“He was so kind and empathetic – and I am so, so proud of him. It was black and white; he should not have died.”

The family thanked their legal team, for their help with the case, and the jury, for “coming to the right decision.”

Beverley Murphy, chief nurse, said: “Our thoughts this week have been with Matthew’s family and friends. We are so sorry for their loss.

“We reviewed Matthew’s care and treatment following his sad death. As we shared with the coroner, we immediately strengthened our processes on how we share information about leave with families.

“We have acted on the inquest findings and continue to improve so that we can provide the best care possible.”

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