From the
Cornish Guardian:
Health chiefs have apologised after a mentally ill man escaped and plunged 60m (200ft) from a viaduct to his death.
Paul Honey, 43, who had previously tried to kill himself, absconded while being driven from a psychiatric unit in Redruth to one in Bodmin with another patient.
Despite a strict policy that two NHS care workers were needed only one was with the two patients on August 19, 2009.
Just hours later Mr Honey, from Bodmin, walked along the platform at Redruth train station and fell from the viaduct. He died from multiple injuries.
Yesterday (monday) Cornwall coroner Dr Emma Carlyon recorded an open verdict following a three-day inquest held last week at Truro.
She said the legal level of proof required to prove Mr Honey intended to commit suicide had not been made out.
The court heard shortly after Mr Honey had run away he was stopped and questioned in Truro by two police officers after accosting a woman.
When officers carried out a database check the correct file was not searched and Mr Honey was not detained ^ the officers then gave him a lift to the railway station.
After the verdict Cornwall Partnership NHS Foundation Trust (CFT), who were looking after Mr Honey, issued a statement which read: ^CFT can only apologise and extend its heartfelt condolences to Mr Honey^s family and friends for the tragedy that followed a breach in trust patient transport policy and procedures. Mr Honey was a much- loved member of the community.^
Philip Confue, acting chief executive, said: ^The trust conducted a thorough investigation following Mr Honey^s death and senior trust staff met with his parents a number of times to consult with them and to listen to their concerns in an effort to ensure that measures would be put in place to prevent any further incidents of this nature happening again. Following our own rigorous investigation, recommendations were put forward and an action plan developed to improve policy and procedure. Disciplinary action was also taken against those staff members who did not comply with trust policy and procedures in this instance. We have noted and respect the findings of the coroner and will continue to work with other agencies, including the police, to improve the level of care and services provided to people with mental health illnesses and conditions in Cornwall.^
A police spokesman said new training for officers had been brought in following an investigation. He said: ^The investigation has led to substantive steps being taken to improve procedures and practices and new training initiatives are already in place, with others to be introduced shortly.^
