By Julie Armstrong
local democracy reporter
The harrowing last voice recording of a 19-year-old before he jumped to his death was played in Surrey’s coroner’s court on Thursday (May 26).
Hearing the final words of Daniel Mattin thanking his friend and apologising for what he was about to do brought listeners to tears.
Daniel left the voicemail for a fellow patient at Guildford’s mental health hospital while healthcare staff, knowing he’d been allowed to go out by mistake and had said he intended to end his life, searched for him and tried to bring him back to safety.
Daniel had formed a close platonic friendship with who must legally be referred to as Miss L, and the way they interacted was described by mental health nurse Alice Moseley as “lovely to see”.
He had recently sat up all night “giggling and laughing loudly” with Miss L until 5am, with staff having to tell them several times to lower their voices.
In his last message to his friend before he jumped from a building, Daniel said: “I don’t think I could have had a better last month of being alive than when I was spending time with you talking. You’re going to be the last thing that I think of.”
He told her to tell his parents he loved them. He gave no explanation.
Daniel, whose personality test had proved inconclusive because of his “random responding”, was described as “an enigma” by coroner Darren Stewart.
After having an argument with Miss L, Daniel had told a member of Farnham Road Hospital staff “he cared for her, but it was just too easy to manipulate her”.
Miss Moseley told the inquest: “I remember as a team, because of his warm nature, being very confused about why he scored so high on narcissistic.”
Psychiatrist Dr Khalid Mirza, Daniel’s responsible clinician, suggested he had asked to be let out of the secure building by the most junior member of staff on the ward that day because he was “an intelligent boy”.
A plan directed by Dr Mirza two days before said if Daniel insisted on going out, the nurse should use Section 5(4) of the Mental Health Act to hold him there.
His risk had elevated since staff learned he had told Miss L he didn’t care if a pain he had was investigated because “he planned to be dead… he planned to do this in a few days whether he was an in-patient or not”.
The inquest heard the doctor’s direction should have been on the nurses’ handover on the morning Daniel left, on June 4 last year.
Miss Moseley, nurse in charge on the ward that day, agreed the document was “out-of-date and incomplete” and underestimated Daniel’s risk to himself at that time.
She told the coroner: “There’s 18 patients and updating them every week plus on SystmOne, there is space for error.”
SystmOne is an online system used by Surrey and Borders Partnership NHS Foundation Trust, which manages Farnham Road, to hold patients’ electronic health records.
As clinical team leader Miss Moseley should as standard practice be consulted before a patient goes out, the court heard, but she was informed Daniel had gone about two hours after he left.
On the 999 call to police where she reported Daniel missing, played to the jury, Miss Moseley could be heard saying “It’s an easy mistake to make”.
This was directed at the student nurse who had allowed Daniel to go out.
Afterwards, Miss Moseley told jurors: “I want to explain how stressed I was when making that call.
“I’m aware that it completely does matter. I was worried, and we do make mistakes, and I just wanted to reassure her.”
As well as psychiatric bed capacity being under a period of black alert, indicating the most severe level of pressure, that day they were discharging three patients and had to share staff with another ward.
“It’s a very chaotic place, Juniper Ward,” she said. “It is a high workload a mental health nurse has.”
The inquest continues.
See also: Guildford Teen ‘Went to M&S to Buy Birthday Present’ Before Ending His Life
Anyone struggling with issues mentioned in this story can call the Samaritans without charge on 116 123.
This website is published by The Guildford Dragon NEWS
Contact: Martin Giles mgilesdragon@gmail.com
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