A SERIOUS case review has concluded a Hampshire hospital "failed" a suicidal teenager who it allowed out on a weekend visit home – where hours later he killed himself.

George Werb “calmly” stepped out in front of a train just 45 minutes’ walk from his house hours after being let out from The Priory hospital near Marchwood.

Now a safeguarding children’s board has found “poor practice” at the secure Kingfisher Ward where the 15-year-old was being treated.

Its damning probe follows an inquest into George's death where the Hythe Road hospital was heavily criticised.

George’s family believe staff did not properly weigh up the dangers of the weekend visit and believe he would still be alive if they had.

The teenager suffered depression and delusions that medicine was damaging him.

In particular, he feared the drug given to him on the eve of being allowed home – terrified it had permanently damaged his brain on a previous occasion.

Among the failings highlighted in a serious case review report were:

• George’s consultant psychiatrist Dr Carlos Hoyos failing to keep records following his consultations with him and also other child patients

• A hand-written risk assessment incorrectly typed into the computer system, changing suicide risk from YES to NO the day before George was let out

• Current or past risk of self-harm or suicide not documented in management plan following admission on May 23 - the day after which George tried to take his own life on the ward

Two days before the teenager’s death, on June 28 2013, a Priory staff meeting found "no current risk of suicide".

But the report states: “This contradicts the handover sheet for the June 25, the day before the ward round, which noted ‘George woke up low in mood and that he felt suicidal’ and confirmed in the nursing notes from June 24 which states that George approached staff saying he felt ‘low in mood and suicidal.’"

And it said there were no nursing notes showing that George's mother, Joanne, had been informed of George's suicidal thoughts when she collected him for home leave on June 27.

Dr Hoyos also "failed in his duties to keep notes”.

His professional regulator, the General Medical Council (GMC) requires this. It is currently investigation him.

He no longer works for the Priory, working now for Solent NHS Trust which provides Hampshire's mental healthcare.

Trust medical director Dr Tony Snell said: “I can confirm that we are aware of this matter but due to an ongoing investigation by the GMC we are currently unable to comment on the finding."

A Priory spokeswoman said: “We are committed to providing the safest and highest quality services for our patients and their families so we welcome the report arising from the serious case review and are already responding to its findings to further enhance the services we provide."

David Taylor, chairman of the Devon Safeguarding Children's Board, which carried out the serious case review said it was unclear whether George's death could have been avoided. 

But he said: "It is clear that the mental health system for young people, from early diagnosis through to treatment, failed George and his family.

"This has been a tragic end to a young boy's life."

The board has agreed an action plan with all agencies involved in mental healthcare for children and young people to create a more joined up and responsive service.

This includes more investment in early help services which will identify problems sooner and offer appropriate and timely intervention.

In addition it has asked NHS England to ensure that they are monitoring the quality of residential mental health provision for young people that they commission and making sure there is effective risk management in place.

George's parents are taking legal action.

This followed an inquest where assistant coroner Lydia Brown criticised the Priory for not adequately risk assessing George’s home visit.

She also concluded the teenager's parents would have never have taken him home to Devon if they had known just how unwell he was.

Speaking to the Daily Echo after the serious case review's publication, George’s family's solicitor Mark Bowman of Fieldfisher said: “I am pleased to note that the review highlights the failings in George's care including the incomplete and/or inaccurate risk assessments and the lack of consultant notes, not only in George's case but also in the case of all other children on the ward at the time."