The widow of a suicidal man who took his own life just hours after mental health specialists sent him home says her husband died because he was ‘let down in his hour of need’.
Steven Clayton, 48, confessed to considering killing himself the previous day when he was urgently referred to the specialist mental health assessment team in Wigan by his GP.
Despite this he was simply given antidepressants and discharged home without any specific advice being provided to he or his wife on how to cope should he begin to develop similar feelings again.
That night, whilst his wife was asleep, Mr Clayton left the family home in their car and was later found in dead a local woodland area.
An internal investigation by North West Boroughs Healthcare NHS Foundation Trust subsequently raised concerns about the ‘clinical practice and competency’ of the senior nurse practitioner who assessed Mr Clayton before he was allowed to return home.
Errors highlighted included not using evidence-based assessment tools fully, not assessing properly the seriousness of his condition and not providing Mr Clayton nor his family with any written crisis plan.
Now his widow, Deb Clayton, 51, says her husband died because he was let down ‘in his hour of need’, and is pursuing legal action against the trust through Hudgell Solicitors.
Illness was sudden but specialists ‘didn’t do all they could’
Mrs Clayton, of Wigan, says she and the five children they had between them lost a ‘wonderful, loving and funny man.’
Mrs Clayton says the first signs of her husband’s illness came when he went on a golfing holiday with friends in September 2017. He had no previous mental health problems and had never previously been prescribed anti-depressants.
She said: “He became unwell very quickly. Just the week before he’d died he’d been on a golfing holiday with friends in Turkey and I knew something wasn’t right when he called from there. He was emotional and saying he wouldn’t be going on holiday without me again.
“When he got back home he wasn’t right. He wasn’t making sense in a lot of the things he was saying and was paranoid about the people he had been away with. He felt they had been talking behind his back and on an online chat group, which wasn’t the case.
“I’m not sure what happened to him when he was away but he wasn’t the same man when he came home, and it was really strange because he’d had no previous mental health issues at all. It came from nowhere.”
Mrs Clayton says her husband called her when she was working a later shift at around 3am on the night of September 26, 2017.
She says he was clearly distressed and considering taking his own life. Despite this, she only became aware of the full extent of the mental anguish he was in when he spoke to the assessment team later that day.
“Steven asked me on the way to see the specialists what would happen and I said that they’d probably be asking a lot of questions and assessing him on some sort of scale before deciding what to do,” she said.
“When we got there is was more of a general chat about what had happened and how he was feeling at the time. I was surprised by that but trusted them as they are the experts and experienced in judging people’s state of mind and supporting them.
“Looking back now I feel they just didn’t do all they could for him. He really opened up and even told them how he’d researched ropes and nooses and how he’d at one point put it around his arm to test it and then around his neck, but that he cut it at that point because he didn’t want my daughter to come home and find him.
“I was so shocked but also very proud of him for admitting how he was struggling. He seemed very calm and I hoped we were heading in the right direction, but I expected more to be asked and more in-depth assessments given what had happened over the past couple of days.
“They gave him anti-depressants and suggested they’d be enough to stave off the suicidal thoughts, then they sent us on our way.
“I simply put my trust in them, and was probably just trying to be positive and convince myself if would all get better, but we all feel so let down now.”
Legal case cites ‘negligent’ care and alleges suicidal thoughts were not properly considered
Solicitor Laura Larkin, of Hudgell Solicitors, represented Mrs Clayton at the inquest into her husband’s death, and says serious questions must be asked of the assessment carried out and the lack of support provided to he and his wife when retuning home.
She said: “The coroner at inquest accepted that Steven’s intent had been affected by mental health and said so in his narrative conclusion. That cannot be doubted.
“The internal investigation into the care provided by the Wigan Assessment Team highlighted a number of areas of concern, including questions over the practices of a senior nurse practitioner who is there to make decisions which can prove the difference between life and death.
“Errors were highlighted such as not using evidence-based assessment tools fully, not assessing properly the seriousness of Steven’s condition and not providing Steven nor his family with any written crisis plan. This is simply unacceptable. Steven’s symptoms were not fully or appropriately explored.
“His suicidal thoughts and intent the previous day were also not properly challenged.
“Mrs Clayton was not asked for her opinions or provided with support herself. She was sent home with her husband still at huge risk – as was evidenced by the tragic outcome – with no written crisis or safety plan, no crisis contact numbers or advice and actions to take should his suicidal thoughts return.
“It was simply not good enough.”
Mrs Larkin said her firm has now written to North West Boroughs Healthcare NHS Foundation Trust alleging negligence, adding: “It is our case that had Steven received a reasonable standard of care he would have been kept safe until his risk of harm diminished and, on the balance of probabilities, his death would have been avoided.
“Had he been properly he could have been admitted to hospital, either on a voluntary basis or detention under the Mental Health Act, or he could have been supported by a Crisis Response Home Treatment Team accompanied by a plan to keep him safe. “
Widow hopes lessons are learned from case
Mrs Clayton hopes other families will now demand more from mental health specialists should their loved ones be taken ill suddenly.
“I fear people like Steven are being let down at the very time in their life when they need help the most and in their hour of need,” she said.
“What chance do people have if they go somewhere for help when they feel this way only to be sent away with no measures in place to protect them. People like Steven are being dismissed and sent away to take their own lives when they don’t know what they are doing. It is shocking and must be stopped.
“This is when health officials should be doing all they can to help and taking the utmost precaution to get things right, yet in Steven’s case procedures were not followed and full assessments were not carried out to properly determine his mental state.
“Nothing can be left to assumption and families should not be losing loved ones to mental health because people employed to provide specialist help are not doing their jobs.
“Steven was let down when he needed people to protect him from himself. He wasn’t the Steven I’d known most of my life at stage, he wasn’t well. He wasn’t in a frame of mind to make his own decisions or certainly to take the decision to take his life, he didn’t know what he was doing.
“Steven often talked about his own dad killing himself and said he could never leave his own family with such devastation. I know he didn’t choose this. If he didn’t want help he wouldn’t have let me take him to the GP, and he wouldn’t have gone to see the assessment team. He didn’t know what he was doing.”
Mrs Clayton says she accepts she may never know what caused her husband’s mental health to suddenly deteriorate, but she feels she must get answers from health officials as to why more wasn’t done to protect him from harm. He would have celebrated his 50th birthday next month.
“What happened on holiday I will probably never know. I’ve wondered whether it was due to the heat or dehydration, but something suddenly happened to his mind,” she said.
“What I do know is that not enough was done to protect him and to help us. We had five children between us and they have all been left devastated like I am and we have all been on medication to help us cope.
“He was such a wonderful man, so funny and so loving.
“He used to love us spending time alone together on breaks. We’d go hiking and hire cottages in the lakes and take our springer dog with us. He was a family man and he was taken away from us far too soon.”