NHS Trusts respond after accepting liability for avoidable death of mental health patient

Two NHS Trusts that accepted liability for the preventable death of Jack Farrington have responded to the Regulation 28 Prevention of Future Deaths Report, outlining changes that they have since made to improve patient safety.

Solent NHS Trust and Portsmouth Hospitals NHS Trust accepted liability in full for the death of Jack Farrington, a 26-year-old man who took his own life while detained under section 2 of the Mental Health Act in January 2020.

The two Trusts’ failings had been found to have contributed to Jack’s ability to abscond from hospital, with improvements needed in the assessment, recording, sharing of information, accountability and implementation of appropriate measures to keep patients safe."

In its response, Portsmouth Hospitals NHS Trust said that it is now working on a new system that will “provide the Emergency Department team with more information about the patient's needs and risks before they arrive.”

Solent NHS Trust said that it is “working towards replacing the paper-based forms with an electronic form” that will feed directly into the existing online system."

Also responding to the case, Professor Sir Stephen Powis, National Medical Director of NHS England, wrote that “details of long-term conditions, significant medical history, or specific communications needs, is now included by default for patients with a Summary Care Record, unless they have previously told the NHS that they did not want this information to be shared.”

Jack Farrington, who had bipolar and schizophrenia, fell from the bridge over the A3 London Road in Portsmouth after absconding from Queen Alexandra Hospital in January 2020.

Jack’s parents, Joseph and Catherine, brought a civil action against both Trusts with the support of top-tier legal firm Tees Law, to hold the Trusts to account in law for Jack’s death. The civil claim concluded in January 2024.

Chantae Clark from Tees Law, who acted for the family, commented: “This case underscores the pressing need for improvements in mental health care and highlights the importance of robust oversight and accountability across the NHS and mental health services.”

An Inquest had earlier concluded that, at the time of his death, Jack was not capable of forming an intention to end his life. When he was lucid, he demonstrated a desire to be well and actively sought medical assistance for his condition.

The events leading up to Jack’s death started in the early hours of 30 December 2019, when he called 999 requesting help because he was having a psychotic episode. He was admitted voluntarily to Queen Alexandra Hospital (QAH) in Portsmouth.

A ‘Mental Disturbance Primary Survey’ scored Jack’s risk as 8, the highest risk level that requires ‘Level 5 (black) supervision’. Despite this, while waiting to be seen for subsequent assessments, Jack was able to abscond through an emergency exit. 

He was later found by the Police and returned to the unit where he was detained under Section 5(2) of the Mental Health Act 1983. Yet, he managed to abscond for a second time the following day using the same route. The police were called again and, once more, they were able to return Jack to QAH.

At this point, Jack was sectioned under Section 2 of the Mental Health Act and transferred to the Hawthorn Ward, a mental health facility under Solent NHS Trust.

A risk assessment of Jack’s mental state was carried out upon his arrival, which identified Jack as having suicidal ideation with specific methods having been considered. Jack was therefore considered to be at high risk of harming himself. 

The Trust had access to documents showing that Jack had already absconded twice within the past 48 hours. Even so, his risk of absconding was not considered by the Hawthorn Ward.

On 2 January 2020, Jack suffered a seizure and was taken back to QAH accompanied by an S1 Bank Health Care Support Worker. He was placed in the “Pitstop” area of the Emergency Department, just 10 metres from the main entrance. Around 90 minutes later, Jack absconded for a third time. He proceeded to take his own life by jumping from a bridge.

In his Prevention of Future Deaths Report, the Coroner warned that “There is a risk that future deaths could occur unless action is taken”. He mentioned handovers and record keeping as key areas of concern. The Report was sent to Solent NHS Trust, Portsmouth Hospitals NHS Trust, and NHS England.

Tees Law’s Chantae Clark added: “Whilst the Inquest process and pursuing legal action cannot undo the pain caused by Jack’s tragic death, I hope that the conclusion of this case coupled with the coroner’s prevention of future deaths report, serves as a catalyst for change. Tees Law have been representing Jack’s family throughout this challenging process. We are pleased that justice has been achieved and that trusts have been held accountable for the shortcomings in Jack’s care.”