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Mum of Teen Failed by Trust Says She Believed They Would Help Him

Published on: 17 Jun, 2022
Updated on: 18 Jun, 2022

By Julie Armstrong

local democracy reporter

The mum of a Guildford teenager who died after being let out of Guildford’s psychiatric hospital against medical advice says she believed he would be saved in its care.

Following the conclusion of a three-week inquest, Dawn Marsh said she hopes the pain she and husband Alan, Daniel’s stepdad, have endured results in “more than cosmetic changes” at the mental health NHS trust.

On Wednesday (June 15) the inquest jury concluded that systemic failings of Surrey and Borders Partnership NHS Foundation Trust caused or more than minimally contributed to the 19-year-old’s death.

See also: Inquest Jury Finds Surrey NHS Trust Fatally Failed Guildford Teenager

Mr and Mrs Marsh said: “As parents we were, to a degree, relieved when Daniel was admitted to the care of Farnham Road Hospital because we believed he would receive the professional help he needed at that point in his life.

“Through the process of this inquest it is apparent that our confidence in the system was misplaced and mistakes were made leading to the most dreadful of outcomes.

“We hope the pain we have endured results in more than cosmetic changes and real improvements are embedded for the care of patients.

“This in turn, will hopefully provide future parents the reassurance that their loved ones receive the highest levels of care that is expected.”

Daniel was Dawn’s first-born child and he walked her down the aisle when she married Alan.

The jury also found that his death had been contributed to by neglect.

Daniel took his own life in June 2021, about four-and-a-half hours after leaving hospital.

On June 1, when Daniel had been at Farnham Road Hospital for about a month, another patient reported to staff that he said he was still suicidal and planned to end his life in a few days.

Daniel’s consultant psychiatrist as a result instructed Daniel should not leave the ward and if he tried to, staff should consider using Mental Health Act powers to stop him.

But this plan was later deleted from the trust’s handover notes.

And on June 4, a student mental health nurse who told the inquest she had not been made aware of the consultant’s instructions, allowed Daniel to leave the hospital.

She said no concerns had been raised about Daniel during the nurses’ handover meeting that morning, and she was not aware it was against the trust’s policy for unqualified staff to grant patients leave from the ward.

She said she had signed patients out on at least 10 occasions without being challenged by senior staff, and had seen other non-qualified staff do the same.

Leigh Day’s Sophie Wells, solicitor for Daniel’s family, said: “The evidence which emerged at the inquest was damning and we are pleased that the jury has recognised that systemic failings caused or more than minimally contributed to Daniel’s death and that his death was contributed to by a gross failure to provide basic care.

“We hope this will now prompt the trust to make long-overdue changes.

“Dawn and Alan have sat through each day of the inquest as evidence of these and multiple other failings has emerged.

“I, like the coroner, am in awe of the grace, resilience, and compassion with which they have done so.

“The testaments from Daniel’s friends show he was a credit to his family, and they have been a credit to his memory.”

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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