Devastated parents of Chorley man found dead on train tracks call for lessons to be learned after a series of care failings

Alex Turner went missing from the Eagleton Ward of Salford Royal Hospital’s Meadowbrook Unit, on December 5, 2019. His body was found near Eccles station the next morning.

An inquest has heard that Alex had spoken many times about wanting to end his life in the lead up to December 5, and that appropriate steps were not taken to manage the risk of him doing so.

His mother, Andrea Turner, said: “Ironically, our son couldn't have been more vocal about being suicidal and needing help, and he was even vocal about how and where he was intending to end his life. Despite him being so vocal, he still lost his life."

The inquest into his death heard that Alex had been diagnosed with Emotionally Unstable Personality Disorder shortly after being admitted as a voluntary inpatient to North Manchester General Hospital’s Safire unit on November 24 following multiple suicide attempts.

Alex told staff that he heard a voice in his head telling him to kill himself, and his father raised concerns that Alex had said he would jump in front of a train if he was discharged. Alex had repeatedly told staff that he would kill himself by jumping in front of a train, the hearing was told.

Discharged without family told

Despite this, the court heard that Alex was discharged without his family being told on November 28 and was sent in a taxi to the local housing office. Within hours, Alex was admitted to the Eagleton Ward at the Meadowbrook Mental Health Unit after council staff called an ambulance due to concerns that Alex would take his own life.

Series of failings

At the beginning of the two week inquest at Bolton Coroner’s Court, assistant coroner Catherine Cundy read out a series of failings admitted by Greater Manchester Mental Health NHS Foundation Trust (GMMH), including that there had been “a failure to formulate a comprehensive discharge care plan for Mr Turner’s discharge from SAFIRE Unit” and “a failure to fully involve and engage Mr Turner’s father in the discharge.”

Suicidal thoughts

During his time on Eagleton Ward Alex reported suicidal thoughts. On December 2, he told a consultant psychiatrist that he was hearing a voice in his head telling him “to go to the bridge” and that “he was going to throw himself into a train but his girlfriend asked him not to.”

Later that day he told a nurse that he had “tried to jump off a bridge” but had been stopped by his girlfriend.

On December 4. he told a nurse that whilst on leave from the hospital with his girlfriend he had "tried to jump off the bridge on Stott Lane” which was yards from the unit “but couldn't climb over the railings". He also reported hearing the voice of the devil in his head.

According to medical records read out at the inquest, during a two hour appointment with a student nurse on December 5 Alex “reported that he had suicidal ideation and he wanted to be put on a section as he was unable to keep himself safe in the community”. The court heard he became distressed and shouted that the devil was telling him to kill himself.

Later that day, during an appointment with a trainee psychologist, the court heard that Alex “expressed high levels of suicidality and stated that he was concerned about keeping himself safe if he was released from the ward”. The medical records stated that Alex “felt sure he would make a suicide attempt and he stated that he would go to the train tracks”.

Leaving the ward

At around 8.30pm on December 5, Alex asked a member of nursing staff if he could leave the ward. The nurse told the court that he was not aware of how Alex had presented to the student nurse and trainee psychologist earlier in the day. He allowed Alex to leave the ward without an escort.

Failures by Greater Manchester Mental Health NHS Foundation Trust (GMMH)

At the beginning of the inquest GMMH admitted that whilst Alex was on Eagleton Ward there had been failures to:

- "Involve and engage Mr Turner’s father in risk formulation and risk management planning”

- Fully record information which was significant to risk assessment and management”

- “Ensure that risk information gathered by [the trainee psychologist] was disseminated to staff on duty”

- “Fully assess the escalating risk of Mr Turner harming himself on 5 and 6 December 2019”

- “Formulate a robust risk management plan to address the escalating risk on 5 and 6 December 2019”

Delay in calling British Transport Police

The inquest heard that GMMH telephoned Greater Manchester Police (GMP) shortly after midnight on December 6 when Alex failed to return to the ward. Despite staff telling GMP that Alex had previously attempted to climb over the Stott Lane railway bridge it was not until 3.45am that GMP contacted British Transport Police (BTP).

A GMP search coordinator told the court that he expected that his colleagues would ask BTP to search the tracks within a 300 metre radius of the ward, which included the tracks under the Stott Lane bridge, but no such request was made.

The court heard that the BTP control room breached its own procedures by failing to ask what GMP wanted them to do, before grading the call as low risk requiring no further action. Shortly after 5am Alex’s body was found on train tracks under the Stott Lane bridge.

Inquest conclusion

The inquest concluded: “Alexander James Turner took his own life in part because the risk of him doing so was not fully recognised and appropriate steps were not taken to manage the risk of him doing so. His suicide was contributed to by neglect.”

Alex's parents

Speaking about her son after the hearing Alex’s mother, Andrea Turner, said: “Suicide awareness and suicide prevention are words you hear all the time these days. Young adults are especially encouraged to speak out and get help.

“Ironically, our son couldn't have been more vocal about being suicidal and needing help, and he was even vocal about how and where he was intending to end his life. Despite him being so vocal, he still lost his life.

“As parents, we had no training in how to keep Alex safe, no processes or procedures or manuals to follow. All we could do was to trust that the professionals knew what they were doing. Nearly two years after Alex’s death we still can’t get our heads around how badly those same professionals let him down.”

Alex’s father and former firefighter, Matthew, said: “Alex was such a loyal, loving and sensitive person. As a family we have been devastated by his loss. I believe that he desperately wanted to get better and he deserved a chance at life. He just needed GMMH to take him seriously, keep him safe and give him hope that he could get better.”

Alex's brother

Alex’s brother Oliver said: “Alex was a very caring and loving person with a fantastic sense of humour. He would always light up the room with his personality. He would always think of others before himself. As his younger brother, he made it his life goal to protect me. Losing Alex has been the most difficult thing to come to terms with. Life will never be the same without Alex. I miss him more and more every day."

What the lawyer says

Gus Silverman, the specialist inquest lawyer at Irwin Mitchell who represented Alex’s family alongside Kirsty Brimelow QC, said after the hearing: “It’s hard to imagine what else Alex needed to do in order for his risk of suicide to be taken seriously and for a proper plan to be put in place to keep him safe.

“The fact that such a vulnerable patient could be prematurely discharged from one unit by being put into a taxi, before being readmitted the same day to a different unit which then failed to put in place a meaningful care plan is shocking. GMMH told the court that it has made significant changes following Alex’s death. That is the least that Alex’s family, and people of Greater Manchester, have a right to expect.”

What GMMH say

Gill Green, Director of Nursing and Governance at Greater Manchester Mental Health NHS Foundation Trust (GMMH) said: “Our deepest condolences go out to Alex’s family, friends and all who cared for him at this sad time.

“As an organisation, we are committed to learning from these incidents. We have undertaken work to thoroughly understand the circumstances surrounding it and from this, we have developed a comprehensive set of recommendations and actions – against which we have made significant progress - to prevent any similar incidents in the future.

“However, we fully accept the findings of the Coroner, and recognise there is further work to be done. This will be actioned as a top priority.”

Charity INQUEST

Nancy Kelehar, a caseworker from the charity INQUEST, said: “Poor planning around discharge, lack of communication between staff, and failing to heed clear warnings from patients and their family members are problems that we see far too often in mental health units across the country.

“In this case, these failures have resulted in tragedy for Alex and his family. Substantive improvements to care planning and risk management processes must be made without delay within GMMH services and nationwide in order to prevent similar unnecessary deaths in the future.”