The coroner's inquest into the death of Matthew Arkle, 37, who died in April 2017 whilst at Wedgwood House in Bury St Edmunds, has recorded a verdict of suicide.
Matthew was admitted to Wedgwood House mental health unit in Bury St Edmunds, which is run by Norfolk & Suffolk NHS Foundation Trust, in February 2017, following an overdose. It was reported that his auditory hallucinations had worsened, particularly at night, and he was smoking more, which in turn impacted on the effectiveness of his medication.
In early April, his care co-ordinator expressed concerns about his depressed mood, which his family had witnessed as well and they were sufficiently worried that they requested the hospital not to grant him unsupervised leave, as they were visiting London for the day on April 4th and they didn’t want Matthew, who could be forgetful, to feel abandoned, as they usually visited him every day.
On April 4th Matthew requested, and was allowed, an hour’s unescorted leave in the evening, despite the family’s request. The inquest heard that the discharging nurse was not aware of the family’s request or the concerns expressed by his care co-ordinator the day before but assessed Matthew as suitable to be granted such leave.
By late evening, he hadn’t returned, and the police were alerted. They contacted his mother who was at this time unaware that he had gone missing from hospital. The following day, the police increased Matthew’s missing person risk level from medium to high.
On Thursday morning, the special search unit, assisted by search and rescue volunteers, found Matthew’s body within Wedgwood House’s grounds near the car park.
“The Court heard that there were repeated basic failures at the Hospital including fundamental issues such as record-keeping and key individuals not knowing of the family’s wishes not to give Matty unsupervised leave. In addition, his fantastically dedicated care worker – who had known Matty for years – had the day before highlighted that it was the lowest that she had seen him for a long time.
“Had such information been available and had the family been contacted earlier by the Trust when Matty disappeared, which it is accepted that they should have done, the Police and search teams could have been actively working sooner to locate him. These failures meant there were missed opportunities to possibly help prevent this tragic incident. The Police have confirmed that they would have treated Matty as a high risk missing person and drafted in support for the search.”
Speaking after the verdict, Matthew’s mother, Sheila, said:
“We thought Matty was safe because he was in hospital. He was let down by the people who were meant to be looking after him. Nothing can bring Matty back, but if just one family could be spared of going through what we’ve gone through then there is a legacy for Matty…”
Tim Deeming said: “This is not the first incident to have occurred at the Hospital Trust, and it must be devastating for families who have gone through a similar experience to hear of such repeated concerns.
Given the evidence that has been heard and the jury’s findings it is heartening to hear that the Coroner will be submitting a Prevention of Future Deaths report so that effective lessons are learnt as widely as possible and similar circumstances avoided, taking into account the highlighted failures identified by the jury which were:
- Failure of appropriate record keeping
- Failure of verbal and written communication
- The general high level of activity and stress on the ward
- The delay in noticing, reacting to and reporting Matthew as missing
- The timing of Matthew’s release, being the late afternoon.
Please note: the family has specifically requested not to be contacted by the media and have asked that any enquiries should be directed to Tim Deeming at Tees Law: firstname.lastname@example.org
Free, confidential advice on medical negligence
Our medical negligence lawyers are based in:
But we can help you wherever you are in England and Wales.
Chat to the Author, Tim Deeming
Partner, Medical Negligence, Cambridge officeMeet Tim
- Areas of expertise
I am very grateful to Tim not least because I feel vindicated in bringing a case of medical negligence against my defendants. I now know that my care was more substandard than I previously had realised. Clearly, I am also relieved to be awarded the means to provide for my future care needs.
I found Tim to be very kind, empathetic, unflappable, thorough, proactive and a good communicator. He guided and supported me through this not so pleasant journey, making it as bearable as possible.
I approached Tim with a certain issue, but with careful probing, it became clear that I had more than one grievance.
From initial contact through to settlement, the Tees Law team in Cambridge provided a professional and compassionate service. I was ably guided and provided with timely well considered advice that has ultimately led to a settlement in line with my expectations – thank you Sophie Stuart and Tim Deeming.
Legal 500 UK 2023
"Tim Deeming was the partner we dealt with, and he was always available to answer any questions or issues we had. He guided us through the minefield of two inquests, mediation, and always with a sensitive approach to our feelings. He was outstanding in his advice and also realistic which was very important as to the expectations of the legal process. Finally he was encouraging when we had to give evidence and was always on hand to help with statements and any evidence we needed to provide."
Legal 500 UK 2021
"Tim Deeming is supportive, friendly, knowledgeable, willing and comforting. I feel protected in his care."
Legal 500 UK 2021
"Tim Deeming has been outstanding for me. This has been a very personal, emotional and challenging event for me. I know that Tees are a business, but I’ve only ever felt like an individual; one who matters, one who deserves fair treatment."
Mr and Mrs Robin Lincoln
Tim Deeming took me through the settlement process step by step and was a master tactician in the final negotiation, who I was proud to have represent me. Katheryn Riggs gave me all the support to file the claim. Tees draw on their vast experience to bring the very best medical experts to the table.