Inquest Finds Suicide Victim's Death was Contributed to by Neglect

The devastated family of a man who committed suicide after repeated calls for help ‘fell on deaf ears’ have called for more to be done to prevent future tragedies after an Inquest into his death found that the NHS Trust responsible for his care was at fault.

Terry Bennett, 45, had a long history of serious and complex mental health problems which required periods of hospitalisation, and meant he struggled to live independently.

But despite the extent of his needs being well known to Avon Wiltshire Mental Health Partnership NHS Trust, he took his own life at his family home in Warminster following a relapse.

His family contacted INQUEST, a charity providing support and expertise on state related deaths and their investigation to bereaved people, and were represented by Public Law Solicitors from Simpson Millar amidst ‘grave concerns and doubts’ about the care Terry received in the months, and in particular the final hours, leading up to his tragic death.

Today, their Solicitor said they felt they ‘finally had the answers and the justice they had been fighting for’, after a Jury at Wiltshire Coroner’s Court, Salisbury, concluded that he died by suicide, but that his death was ‘contributed to by neglect’ (14th September, 2018).

Tracee Cossey, Terry’s sister said, “My brother was a loving, creative, intelligent and warm hearted man, who was also very ill and had been for many years. The family relied on professionals to support Terry and to keep him safe, yet he was allowed to drift and deteriorate without anyone being aware of how poorly he was or take steps to help him and stop him from harming himself”.

Following the conclusion of the Inquest, a Public Law Solicitor said, “The family have fought long and hard to expose the circumstances surrounding Terry’s death, and to understand whether more could, and should, have been done to help him in his final hours”.

“Throughout the Inquest the Jury heard evidence of a general, and yet very basic system failure to ensure adequate care for Terry resulting from a lack of staff expertise, supervision, team communication, record keeping and case review”.

“The consequences of such failings have been quite devastating, and the family are now calling on Avon Wiltshire Mental Health Partnership NHS Trust to ensure that immediate measures are put in place to prevent future tragedies, and that any such measures are communicated to the public to provide reassurances to those who rely on the service for their own wellbeing, and the wellbeing of their loved ones”.

Terry took his own life on 27th of October, 2016. He had battled mental health issues for much of his life, and was under the care of Avon Wiltshire Mental Health Partnership NHS Trust where he had previously been allocated a care coordinator from a Community Care Team whilst receiving support from a psychiatrist.

However, despite his background, it is now understood that he was discharged from his Community Treatment Order with inadequate planning, and that once discharged he had received inadequate support.

A Solicitor from Simpson Millar said, “As part of the Inquest the Jury heard that Terry’s mental health began to deteriorate in September 2016, at which point he had not been seen by the support team for four months”.

“Despite his mother’s desperate efforts to prevent him from self-harming he took his own life on October 27th. She remains devastated that her repeated calls for help from the Community Care Team simply fell on deaf ears”.

“His family feel strongly that had he received the support he so greatly needed his tragic death could have been prevented, and are relieved that the Inquest has supported their concerns”.

Terry’s sister Tracee added, “Finally, the family have been given the opportunity to discover the true extent of the failings, received an sincere apology from the NHS Trust and had our doubts and concerns supported by the Jury and the Court”.

She went on to thank the Jury and Assistant Coroner Nicholas Rheinberg for their time and careful consideration throughout the Inquest which started on 3rd of September, 2018 and lasted two weeks.

Deborah Coles, Director of INQUEST said, “The failures highlighted by this Inquest show a familiar story of a family left to care for someone profoundly unwell, only helped when things meet crisis point. For Terry this was far too late. The deficiencies in the systems and practices of Wiltshire mental health services evidenced here, should be considered at a national level”.

This information was originally published on our website on 14/09/2018.

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