Mother says NHS unit which released son before his death ‘not safe’

The mother of a man who took his own life says the NHS unit where he was treated is “not a safe institution”.

Despite Jayne O’Sullivan’s 39-year-old son Dan telling a psychiatrist at a west London mental health unit of his plans to kill himself, he was allowed to leave and was later found dead.

A coroner found Central and North West NHS Trust failings were a “significant contribution” to his death.

The NHS trust said it “deeply regrets” Daniel’s death and had made changes.

Mrs O’Sullivan has been awarded compensation but says she still doesn’t know why her son was released from the mental health unit at St Charles Hospital in Ladbroke Grove.

Warning: this story contains details about mental health, addiction and suicide that some may find distressing.

Mrs O’Sullivan, who is originally from north London but is living in Stevenage, Hertfordshire, said her son had mental health problems for at least a decade, including episodes of paranoia.

Dan was diagnosed with emotionally unstable personality disorder, but Mrs O’Sullivan explained he was “in denial” about his health and would self-medicate with drugs and alcohol.

“I was getting phone calls from him late at night, saying ‘they’re out to get me’,” she said, adding Dan would often stay overnight at her house or go abroad for a few days.

When Dan returned from these trips, he would sometimes be admitted to hospital and treated with antipsychotics.

In the month before Dan’s death his mental health worsened and on several occasions he mentioned suicide.

On 13 March 2019 he tried to take his own life, until he was discouraged by a member of the public on Vauxhall Bridge in central London.

Police officers took him to A&E at Kings College Hospital and he was sectioned under the Mental Health Act.

He was transferred and admitted to the mental health unit at St Charles Hospital on 19 March, where he remained under section.

During an assessment, Dan said he planned to kill himself “next Tuesday”, but the hospital’s consultant psychiatrist decided to rescind Dan’s section detention six days later – even though he maintained his delusional and paranoid beliefs were real.

On the next afternoon – a Tuesday – staff allowed him to leave for a short time to buy cigarettes. Dan never returned and wasn’t reported as missing to the Met Police by staff until after midnight, even though he should have been back by 21:00 GMT.

He was found dead at Vauxhall Bridge at 05:30 the next day, 27 March 2019.

Mrs O’Sullivan said the first time she even heard her son had been sectioned was when officers knocked on the family’s front door to inform them of his death.

“I wanted to vomit… I had dizziness, it was a completely out-of-body experience,” she said.

Seeking answers about her son’s death, Mrs O’Sullivan attended Dan’s inquest but was said she was left questioning the care he received.

“The notes say [the hospital psychiatrist] had spoken to Dan on the day he went missing and she felt that Dan was OK, but there was no evidence of any suicide risk assessment,” Mrs O’Sullivan said.

“How can this happen? He was in a mental health unit where you’d hope they’d pick up on the risk. In my opinion it’s not a safe institution.”

During three days of inquest hearings Mrs O’Sullivan said “there was no acknowledgement of what I consider a heinous crime”.

Eventually, Mrs O’Sullivan hired Nicola Wainwright from JMW Solicitors to pursue legal proceedings against the NHS trust because she felt Dan “hadn’t been listened to in life and he was going to be listened to now”.

In a narrative conclusion in October 2022, coroner Christopher Williams said rescinding Dan’s section order had been “a missed opportunity to assertively treat his psychosis and drug use in hospital”, which “made a significant contribution to his death two days later”.

He cited failures to update Dan’s “suicide self-harm risk assessment”, and to “formulate a care and treatment plan identifying core treatment needs”.

The report noted the NHS’s Serious Incident Investigation did not interview the nurse who reported Dan missing to police, nor did it look into the disappearance of a signing-out book at the hospital after his death.

Central and North West London NHS Trust spokesperson said “We deeply regret the death of Mr O’Sullivan and the distress this has caused his family.

“Following this very sad incident we have made a number of changes to our adult mental health services in Kensington and Chelsea and many of these changes have been adopted across the trust.”

In a seven-page response to the coroner’s Prevention of Future Deaths Report, the trust said it had “made a number of changes to the provision of adult mental health services” including a new information recording system, staff training, and updated risk assessment and missing patient policies.

Responding for the Department for Health and Social Care, mental health minister Maria Caulfield also expressed her sympathies over the case and said while care and treatment plans were “not currently a statutory requirement, under the Mental Health Act Code of Practice inpatients should have a personalised care and treatment plan as part of the Care Programme Approach”.

For Mrs O’Sullivan, she says she hasn’t had closure, and still doesn’t know why Dan was released and has not been able to hear from his psychiatrist in person.

“I trusted a mental health service that I was told is better equipped than me,” she said.

“I should have listened to myself; perhaps I could have done more.

“I’ll live with this now until I don’t live any more.”