Family hopes ‘lessons are learnt’ after Sidmouth man dies following mental health ‘failings’

Matthew Llewellyn-Jones.

Matthew Llewellyn-Jones. - Credit: Archant

A Sidmouth man died as a result of serious failings at an Exeter mental health unit, an inquest heard.

Following a four-day inquest at Exeter’s County Hall, a jury ruled Matthew Llewellyn-Jones committed suicide on March 16, 2015 some 24 hours after being sectioned with psychosis, for his own and other people’s safety, at Wonford House at The Cedars.

The inquest heard how the 37-year-old had believed aliens and reptilians were trying to kill him and his family - and the only way for him to save them was for him to sacrifice himself to the gods.

Mr Llewellyn-Jones, who lived in a static caravan, hanged himself after escaping unaccompanied to an unsupervised area near the ward and was found by a member of the public.

He left through a door which should have been locked throughout the day and should have had a sign in place with that message. Devon Partnership Trust, which runs the unit, has accepted this was a serious failure.

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A jury ruled patients and visitors going through the door into an insecure smoking area had increased the risk of the ward’s locked-door policy failing.

It was also noted that there were insufficient risk assessments, both on Mr Llewellyn-Jones’s arrival at the unit and on the following day. Inadequate notice was taken of the information his family and other third parties had, but were not asked for, the jury ruled.

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It was also found that inadequate staffing levels, insufficient and inadequate clinical notes and observations, as well as lack of induction and patient information handed over to the nurse on duty, all contributed to the failings in all the stages of Mr Llewellyn-Jones’s care.

Coroner Lydia Brown told the inquest Mr Llewellyn-Jones had a history of mental health problems, although he had not been hospitalised before. She added that Mr Llewellyn-Jones had become very unwell, which was why he had fashioned a make-shift sword for protection.

In a statement read to the inquest, Mr Llewellyn-Jones’s mum, Roseanne Barrett, said she had become extremely worried about her son on March 14 and had stayed up all night with him.

She said that, on March 15, Mother’s Day, she contacted The Cedars’ mental health team and arranged for a meeting at her home later that day.

But, when Mr Llewellyn-Jones insisted they went out for coffee and then told his mum they would not have another Mother’s Day together, she realised she was not going to be able to get her son home safely. She rang the police, who escorted them to the unit.

The inquest heard that, after arriving, Mr Llewellyn-Jones was assessed by doctors and had admitted he had stopped taking his medication for a couple of months, but said he had recently restarted.

Doctors said Mr Llewellyn-Jones had become acutely unwell and presented symptoms of psychosis, so recommended he be detained for further assessment, medical treatment and therapy, which would help him recover.

To start with, he was under 30-minute observation checks, which dropped to hourly the following day. The inquest heard Mrs Barrett had returned on March 16 and had accompanied her son to a smoking area for a cigarette – she had left at about 1pm.

Mr Llewellyn-Jones was later found hanged at about 4.30pm. He was taken to the Royal Devon and Exeter Hospital, where he was confirmed dead.

Coroner Ms Brown said: “Many matters were of a concern to me. We are 18 months after Matthew’s death. Since then there have been further breaches of that door, but, thankfully, without the same tragic outcome. It would appear further work is required.

“Staffing levels have been of some concern to this jury. I have been advised that almost immediately after Matthew lost his life, it was reduced to a 16-bed unit, although the staffing levels stayed the same.

“Matthew had the love and care of his family, in particular his mother, who was there for him, even in his most desperate of times.

“It would appear his final act was a misguided attempt to protect her - his loss is an irreplaceable one.”

Ms Brown said she would be writing to the trust’s chief executive with recommendations of what could be done to help ensure such failures did not happen again.

Solicitor Chelsea Parkin, speaking on behalf of Mrs Barrett, said: “The family would like to thank the coroner for her time and the jury for their conclusion that was found today.

“The family is grateful with the conclusion that has been reached and the failings that were identified. They hope lessons are learnt from this so that the same thing doesn’t happen again to any other family or individual.”

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