Fire exit blunder is blamed for patient's suicide
REPAIRS to a fire exit at High-gate Mental Health Centre after it had been repeatedly kicked open failed to stop a patient escaping to take his own life, a coroner ruled. An emergency fire door at the Dartmouth Park Hill facility was forced open
REPAIRS to a fire exit at High-gate Mental Health Centre after it had been repeatedly kicked open failed to stop a patient escaping to take his own life, a coroner ruled.
An emergency fire door at the Dartmouth Park Hill facility was forced open numerous times by schizophrenic Carl Dennison, who had a history of absconding and had previously tried to commit suicide.
Repairs were made to the door in the acute Jasper Ward after his escapes, but these failed to prevent the 34-year-old patient leaving for a final time and taking a lethal dose of methadone in a King's Cross hotel room.
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"Carl Dennison took his own life at a time when he was repeatedly absconding from the ward where he was detained and a previous repair to the fire exit did not prevent this," said coroner Andrew Reid at the inquest last Thursday.
A hotel chambermaid found Mr Dennison's body the day before Christmas Eve last year. His disappearance from the mental health ward, run by Camden and Islington Mental Health Trust, was noticed four days earlier.
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He was found with an empty bottle of methadone and a tape recorder next to his body.
On the tape, Mr Dennison apologised to his family for taking his own life so close to Christmas.
As well as schizophrenia, he suffered personality disorders and depression for which he had been receiving treatment in Highgate for more than two years.
"He felt very frustrated being contained on the ward," senior matron Josephine Spencer told the inquest. "His later absconding was because of this."
The inquest heard his method of escape was either to wait by the front door for someone to enter, or to kick through an emergency door.
Repairs were made to the door after each of the seven kickings it received from Mr Dennison over the 10-week period leading up to his death.
Ms Spencer also admitted the door would not have been as strong as it should have been and launched an investigation after the suicide.
"When I wrote my report I did not make any recommendations about the standard of nursing," she said.
"It was about practical things like the fire exit."
Ms Spencer said talks are now going on with the fire brigade to strengthen the emergency doors.
Dr Reid recorded death by suicide after toxicology tests showed lethal levels of methadone in Mr Dennison's blood.
"I am satisfied the [mental health] trust is seeking to learn lessons from Mr Dennison's death and is making recommendations to prevent further fatalities," he concluded.
Speaking during the inquest Carl's father Michael Dennison from Swansea said his son was a bright boy but one who "wouldn't get his head down to the books." He added afterwards: "The verdict was the correct one. But I have no comment to make about the trust's responsibility."