The State of Nottingham Healthcare NHS Trust

Taken from Nottingham evening post
HURTEJ KAUR09:00 - 06 August 2008

NOTTINGHAM MAN HANGED HIMSELF AT QMC

Malcolm Askham was desperate for help. He suffered from manic depression - and had begun to fear he might harm others.He called an NHS crisis team six times, fearing he would hurt his wife and family.Finally, in desperation, he called police and an ambulance to take him to the Queen's Medical Centre in the early hours of May 27 last year.The hospital's emergency staff faxed the psychiatric team to let them know the 55-year-old was there.But the fax machine was in a different room to the team - and Mr Askham was kept waiting for two-and-a-half hours.

After not being seen, he hanged himself in a stairwell at the hospital.An inquest into his death said lessons should be learned from the tragedy. Notts Healthcare NHS Trust said changes had now been made to its procedure. Recording a verdict of suicide, Notts coroner Dr Nigel Chapman said: "I think Malcolm was let down badly that night due to lack of communication and misunderstandings. He may well have done it later that day, but not in hospital."I find it most strange that he could not be seen quickly by the psychiatric unit and have an assessment."His widow, Carolyn Askham, 54, of Ewart Road, Forest Fields, said she knew something was wrong when her husband was not sleeping, but came into the bedroom in the early hours of the morning of the day he died."Malcolm came up and said, 'Something awful's going to happen' and I said, 'No, it's not'," she told the inquest. "I got some sort of premonition and went downstairs and saw the phone was off the hook. Then the police and ambulance came through the door and took him to hospital."

A &E staff nurse Lindsay Whyllie saw Mr Askham when he was taken to the QMC at 5.30am on May 27. She said: "I asked a colleague to call the mental health team to let them know he was in the department and asked for any information and tell them a referral would be made about him. I faxed the referral."At that time fax referrals were sent to A floor in South block - but the Notts Healthcare NHS Trust's psychiatric team was based on B floor, South block. Mr Askham was placed in a sub-waiting area but became agitated so was moved to a cubicle.Ms Whyllie called the psychiatric team again to ask what she could do to help and was advised to get a security guard to sit with him. By this stage Mr Askham was next in line to be seen by a doctor.

Mental health nurse Tammy Locksley went to A &E to see Mr Askham at 8am, but he could not be found.The inquest heard that CCTV shows the 55-year-old had left the department alone. He was found at 10.30am in the East block stairwell, where he had hanged himself.Nichola Turner, night co-ordinator for acute admissions for Notts Healthcare NHS Trust, said the team was not asked by A &E to see Mr Askham. She told the inquest: "At that time, there was nothing indicating that help was required."Dr Chapman asked: "So there's always going to be a delay because of going through A &E which means two hours roughly where he [Mr Askham] can walk off, which he has done."

Mr Askham was diagnosed with bipolar affected disorder in 1991. He was seen at Highbury Hospital in Bulwell in 2005 and then by the crisis team.In connection with the six calls Mr Askham had made the day before his death, Dr Chapman asked Dr Ian Medley, consultant psychiatrist with Notts Healthcare NHS Trust: "When he made the calls, did no one offer to visit? Why would he then phone the police on May 27 when the crisis team are available 24 hours a day?"Mr Medley replied: "I don't know. I think maybe he thought he would somehow harm his family."

Following an investigation, Dr Andrew Dove, Nottingham University Hospitals director of services in A &E, said he could not say why Mr Askham was not seen until 8am or how he was able to leave the department by himself. But he said an action plan had been drawn up which includes more clarity about staff being able to restrain patients and codifying missing patients.

Nick Daibell. who was representing Notts Healthcare NHS Trust at the inquest, said changes had been made, including placing a fax machine in the same office as the crisis team and documenting phone calls.He said: "The conclusion was that the communication was not clear and there was a misunderstanding between the two departments about whether a referral for an immediate visit was made."Dr Chapman added: "To have a fax machine not even in your own department beggars belief. He was able to walk out and take his own life without having a proper psychiatric assessment."He himself dialled 999, he wanted help. He stayed in casualty and became agitated and we know from the phone bills, that he called the crisis team six times the day before he went to casualty."He said these things had not caused his death, which was asphyxia due to hanging.

After the inquest, Mrs Askham, 54, said: "I'm pleased that plans have been put together for the next person that comes along."A joint statement from Notts Healthcare NHS Trust and NUH said: "Previous arrangements for communication between the A &E department and mental health services had worked well over a number of years."However, this tragic incident highlighted the need for a review of those arrangements in order to develop more effective communication between these two services."A spokeswoman for Notts Healthcare NHS Trust said that, previously, anyone admitted with mental health concerns had to be seen by the crisis team within four hours of being taken to A &E. But now they have to be seen immediately.

(And yet the Crisis team still seemed to be under staffed or unable to attend as I saw yesterday- I and they have to be lucky I was not in same mood as MR Askham- sympathy to his family but I fear this won;t be the last tragedy)