Coroner's concerns
Coroner’s Concerns (source excerpt)
I am concerned that five years after the death of Mr Laversuch there is not in place a clear and readily understandable policy framework and guidance for the admission of patients into wards after their detention has been authorised under the Mental Health Act and that there remains, on the evidence heard at inquest, a...
View full coroner's concerns
I am concerned that five years after the death of Mr Laversuch there is not in place a clear and readily understandable policy framework and guidance for the admission of patients into wards after their detention has been authorised under the Mental Health Act and that there remains, on the evidence heard at inquest, a failure by some staff to understand what is required of a safe risk assessment. I recognise and accept that there have been efforts to learn from Richard’s death and formulate the appropriate guidance, but I am concerned that they are still not clear so long after his death.
I am concerned that a patient who poses a significant risk to themselves and others may be admitted to ward unsuited to their risk and that there is a risk of future deaths.
Report sections
Investigation and inquest
An investigation was commenced on 29th November 2021 into the death of Richard Laversuch who was 63 years old when he was unlawfully killed by manual strangulation at Parklands Hospital on 27th November 2021 by a patient, Mr X, who had been incorrectly admitted to an acute ward a few hours previously. A jury concluded that there were failings in the practice of the Approved Mental Health Practitioner used by Hampshire County Council and in the Trust’s staff, policies and procedures when admitting Mr X to the hospital.
Circumstances of the death
Mr X is a young man who suffered a sudden deterioration in his mental health and was admitted to Parklands Hospital in Basingstoke pursuant to s.2 of the Mental Health Act 1983. He presented a high risk to himself and others and was admitted onto a ward that he was not suited for. Within five hours of his admission, Mr X killed Mr Laversuch and attempted to strangle another patient. The Trust accepted that Mr X had been admitted to the wrong ward and there were failures with respect to communication, decision-making, bed planning prior to Mr X’s admission, failures to make appropriate entries on the digital system, failures to risk assess and failures to follow national guidance which more than minimally caused or contributed to death.
Mr X pleaded guilty to manslaughter on the grounds of diminished responsibility. An inquest was necessary to consider the wider concerns articulated by the families of Richard Laversuch and Mr X as well as the sentencing judge.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.
Copies sent to
I can confirm I have sent the report to[REDACTED] OF Richard Laversuch [REDACTED]of Mr X Hampshire County Council Hampshire and Isle of Wight Healthcare NHS Trust The Approved Mental Health Practitioner
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