Inquest Jury Finds Surrey NHS Trust Fatally Failed Guildford Teenager

Published on: 16 Jun, 2022
Updated on: 16 Jun, 2022

Daniel Mattin. Photo supplied by family.

By Julie Armstrong

local democracy reporter

A jury has found a Surrey NHS Trust failed a 19-year-old Guildford man who climbed the barrier of a tall building after being let out of a mental health hospital against medical advice.

After deliberating for seven hours and 40 minutes yesterday (June 15), the jury recorded a unanimous conclusion that Daniel Mattin’s death was contributed to by neglect on the part of Surrey and Borders Partnership NHS Foundation Trust.

The jury, of seven women and three men, found the trust failed to adequately implement Daniel’s risk and leave management planning when he stayed at Farnham Road Hospital for a month one year ago, first under a section and at the end voluntarily.

The jury forewoman read at Surrey Coroner’s Court: “There was a failure in leadership with regards to risk and leave management and student supervision within the hospital over the entire period of Daniel’s admission.”

She described the SBAR system used by staff to communicate a patient’s condition between themselves, at the time of Daniel’s stay last May, as one “created with the potential for failure”.

The record of inquest reads: “Failures included incorrect information, information being deleted, no safety check or audits and students occasionally completing the SBAR without supervision.”

The trust’s head of nursing for working age adults said monthly audits have since been put in place.

How Daniel Mattin was failed by Surrey and Borders Partnership NHS Foundation Trust

In Daniel’s case, his risk level was misrepresented on the SBAR and key information was deleted on the SBAR of June 2.

This meant staff receiving a handover on June 4 did not read about Daniel’s doctor’s instruction to hold him on the ward pending a risk assessment.

And when Daniel approached a student nurse that morning, first to open the laundry room so he could do his washing, then asking for permission to go out, she let him – unaware he had confided in a friend a few days earlier that he planned to take his life within days.

The jury forewoman said unqualified staff approving leave “was not a one-off occasion but occurred regularly”.

The jury determined it “probable” that Farnham Road Hospital staff’s failure to pass on information between themselves about Daniel’s management plan, the inadequate arrangements in place to manage granting leave to voluntary inpatients, and a failure to allocate adequate numbers of nursing staff and consultants to attend multidisciplinary team meetings and ward rounds, all “made a material contribution to Daniel’s death”.

They thought it “possible” that the response by hospital staff on discovering he had been granted leave, including timeliness, also contributed.

The nurse in charge of the ward that day first became aware Daniel had gone at 2pm, a little over two hours after he left.

An incorrect entry on an observation sheet stated he was awake in bed at 1pm, when he was actually out shopping and drinking.

The supervisor instructed a care support worker to call Daniel and tell him to come back, and then went on her break for an hour without checking the outcome.

On her return at 3pm she found Daniel still missing and called him herself. She called police at 3.45pm after she was told of a voicemail he’d left for patient Miss L, in which he 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.”

At this point 1 hour 45 minutes had passed since the supervisor learned of his absence, which was not consistent with the trust’s missing person policy.

Police rushed undeer flashing blue lights it to the Friary shopping centre, because that’s where Daniel had said he was when speaking to staff.

Sadly, they were looking in the wrong place.

It was a nurse from the hospital out looking for Daniel who found him and saw him fall.

He called an ambulance at 4.33pm as he ran down the steps to try to resuscitate him. Daniel died of multiple injuries.

It was 4.30pm when the detective superintendent was asked to authorise tracing Daniel’s phone.

Inspector Pike said this was because the threshold for intrusion was not reached until they had searched in both his last known location and another place where police had picked him up on a previous attempt in May, which led to his admission to Farnham Road.

”People often go where they’ve been before,” he said. “Only then was the threshold for getting a trace on Daniel’s phone met.”

PC Tobie Clapcott, forensic radio frequency practitioner, said in evidence it would take about 45-50 minutes to get Home Office approval and create a map with the radius of possible locations.

He said: “Unfortunately it’s not like you see on films. We are very restricted in what we can obtain.

“We only know the location of the cell tower, not the exact location of the phone. A phone can be connecting to more than one mast at once.”

Inspector Pike added telephone results would only confirm his location to a radius of 100 metres.

Daniel’s family’s barrister, Tayyiba Bajwa, suggested if police had been called at 2pm, they could have started their search earlier.

But the force control room operator told the court if the call had come in sooner there was no guarantee it would have been classed as grade 1, since it was the voicemail Daniel left for Miss L that elevated it to an emergency.

The jury concluded: “A search was carried out in accordance with police procedure.”

Daniel told clinicians he was “internally bored of life and empty” and had attempted suicide a few times before.

It was thought he may have emerging personality disorder but this had not been diagnosed.

Hospital staff found him to be polite and charming and recalled how he once intervened to defend staff when another patient became aggressive.

Another time he had been tearful as the close friendship he developed with Miss L made him think of past friendships.

His group of friends dwindled as they headed off to university and he was said to have distanced himself because of a plan to end his life.

Surrey and Borders Partnership NHS Foundation Trust has been contacted for comment.

Anyone affected by the issues in this inquest can call the Samaritans for help, free 24/7 on 116 123.

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