Lewisham hospital "missed opportunities" to prevent dad's suicide

UNIVERSITY Hospital Lewisham “missed opportunities” to prevent a suicidal dad-of-three from taking his own life minutes after he was discharged from A&E, a coroner found.

Simon Moss, 49, was rushed to hospital in February last year after climbing onto his roof and threatening to take his own life as a result of delusions.

Police managed to coax him down and he was taken by ambulance to University Hospital Lewisham, where he was seen by the psychiatric liaison team.

However, a mental health nurse judged that Mr Moss was not going to kill himself and discharged him from hospital alone after being unable to find his next of kin’s phone number.

Minutes later Mr Moss jumped to his death from a nearby multi-storey car park.

At the conclusion of his inquest on Tuesday, Xavier Mooyaart, assistant coroner at London Inner South Coroner’s Court, said NHS staff should have gone to greater lengths to find a number for Mr Moss’s family before discharging him.

He said this would likely have stopped the dad from leaving the hospital alone and prevented his suicide.

Simon Moss — **PICTURED: Mr Moss took his own life minutes after being released from University Hospital Lewisham**

Mr Mooyaart said: “Further efforts should have been made to identify a number for Simon’s family. This lack of a check was a failure.

“There was a lack of curiosity about its existence and his next of kin details.

“These failures might all be held against that nurse (who assessed him) but it’s plain this was an experienced nurse.

“It’s clear the nurse didn’t do some rushed job. She spent a good deal of time exploring his presentation.

“No one in her team thought to look for a number.”

**PICTURED: Mr Moss was discharged from University Hospital Lewisham without anyone by his side**

The coroner said a second assessment of Mr Moss by a doctor should have taken place – and this would likely have led to his wife’s number being discovered.

Mr Mooyaart added: “There was a clear and credible opportunity had a second opinion been sought that Simon might have been collected from hospital.

“This would have drastically if not wholly avoided the risk of what followed.”

Mr Mooyaart said the mental health team could have asked the ambulance service for the phone number of Mr Moss’s wife.

He added that they could also have enquired about who made the call to 999 or even tried to track down his GP.

Tragically, a number for Mr Moss’s wife and other important details about his suicidal behaviour were included in the notes made by the paramedics who treated him earlier that day.

But A&E triage did not forward these details, which were accessible via the hospital’s iCare admin system, to the emergency department’s mental health team – run by South London and Maudsley NHS Foundation Trust.

During the inquest, the hospital said this blunder was due to “human error”, with staff failing to upload the full notes to the iCare system.

Mr Mooyaart said this “neutered” the psychiatric liaison team’s ability to properly assess Mr Moss.

Mental health nurse Helen Kattall ordered Mr Moss’s discharge after assessing him as she did not think he was going to take his own life.

She previously told the inquest: “He was not mumbling to himself or hearing voices. He was just sitting comfortably and relaxed talking to me.

“I asked him about him saying the CCTV was watching him and he denied that.

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“When I asked him why he was on the roof he said he just wanted space to be alone and think. I asked him of all places to go, why the roof.

“He said nothing really and said he was stressed and thinking a lot. He told me he was stressed because he was being laid off.

“He told me he would never take his own life as he wouldn’t do that to his family. That was powerful for me.”

Ms Kattall said she wanted to let Mr Moss’s wife know about his discharge but did not have her number.

She asked Mr Moss for his wife’s number, however he told her he would let his wife know about the plan – and later said he did not have his phone on him.

She accepted this and ordered his discharge from hospital.

Mr Moss, who worked as a partner at private equity firm Hermes, then went to a nearby multi-storey car park and took his own life.

The coroner said he plans to issue a prevention of future deaths report after identifying “significant” gaps in care and “missed opportunities”.

However, he said he could not make a finding of neglect, instead recording a conclusion of suicide.

For emotional support you can call the Samaritans 24-hour helpline on 116 123, email [email protected], visit a Samaritans branch in person or go to the Samaritans website.

Home » News » Lewisham hospital “missed opportunities” to prevent dad’s suicide

Lewisham hospital “missed opportunities” to prevent dad’s suicide

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