Two Hampshire NHS Trusts have admitted failings following the avoidable death of a mental health patient.

Jack Farrington took his own life in January 2020 aged 26, while detained under section 2 of the Mental Health Act.

Four years on, Solent NHS Trust and Portsmouth Hospitals NHS Trust accepted liability in full for his death.

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 response, 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.

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”.

Professor Sir Stephen Powis, National Medical Director of NHS England, also responded to the Regulation 28 Prevention of Future Deaths Report.

He said: “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.”

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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.

His parents Joseph and Catherine brought a civil action against both Trusts with the support of legal firm Tees Law, to hold the Trusts to account in law for Jack’s death.

The civil claim concluded in January this year.

Chantae Clark from Tees Law said: “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 previously 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 December 30, 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 eight, 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.

He managed to abscond for a second time the following day using the same route.

The police were called and 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.

He was therefore considered to be at high risk of harming himself.

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The Trust had access to documents showing that Jack had already absconded twice within the past 48 hours.

But his risk of absconding was not considered by the Hawthorn Ward.

On January 2, 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.

“We are pleased that justice has been achieved and that trusts have been held accountable for the shortcomings in Jack’s care.”

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