A CORONER has said ‘a series of failures’ by a Sheffield hospital led to the death of a dad-of-two who plunged from a motorway bridge while on hospital leave.
Craig Dore, aged 49, jumped from the M1 viaduct at Tinsley while he was supposed to be on two hours’ leave at his home on Totley Hall Mead, Totley.
He was granted home visits by a psychiatrist soon after being sectioned and admitted to Nether Edge Hospital following an earlier suicide attempt, an inquest at Sheffield Coroner’s Court heard.
Recording a narrative verdict, Coroner Christopher Dorries said Craig was able to leave on December 29, 2010, despite hospital staff finding evidence of him trying to hang himself in his room.
He said Craig should have been placed on one-on-one observation, or been physically prevented from leaving.
“Adequate steps were not taken to protect Mr Dore from a real and immediate risk to his life,” Mr Dorries said.
The coroner also said Craig’s home leave was ‘not fully monitored’. Craig had claimed he needed the visits to go swimming and walking, but didn’t do either.
Mr Dorries told the inquest hospital staff showed a ‘lack of necessary intervention’ when Craig left the ward on December 29, despite being told to stay.
But he said the original decision to allow home leave ‘was not a causative factor in the death’.
Kevan Taylor, chief executive of Sheffield Health and Social Care NHS Foundation Trust, apologised for the failings and said a ‘thorough internal investigation’ had been carried out.
“A comprehensive action plan is now in place in which all of the recommendations have either already been addressed or are in progress,” Mr Taylor added. “The trust recognises the very serious nature of the incident.”