A veteran who took his own life at Matterdale, near Ullswater, had been let down by the health trust covering Cumbria, an inquest has heard.
An inquest into the death on April 17 2022, of Mark Rodhouse, of Penrith, was told that Mark had been medically discharged from the army in 2005 due to a number of physical factors but also his mental health. He continued to battle with anxiety until his problems worsened following a significant crisis in early 2022.
Margaret Taylor, assistant coroner for Cumbria, heard evidence from witnesses from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust in relation to Mark’s mental health care between March and April of that year.
Issues highlighted included poor communication and record keeping at the trust, plus failures to properly consider earlier medical notes before meetings, and risk assessments being carried out.
Ms Taylor was told there was a failure to update key documents concerning care planning, safety planning and risk assessments, and a lack of continuity of care.
Mark rarely saw the same practitioner twice during his involvement with the trust’s crisis team — which was said not to be unusual.
Evidence was given that on April 16, Mark’s daily visits were reduced, which meant he did not receive one on the day of his death. This was despite his risk level having been assessed by an experienced clinical practitioner on April 15, which required him to have daily contact.
Other shortcomings of the trust were described as a failure to properly engage Mark’s family in his risk assessments and safety plans; and to review his medication needs and make appropriate referrals at an earlier point — including to veteran-specific mental health services.
Concluding that Mark had committed suicide, Ms Taylor also found there had been a failure by the health trust to involve his wife, Sharon, in risk and care planning.
As a result, she was unaware of information that may have changed the nature of this risk. This failure possibly contributed to his death.
After the inquest, Mark’s family said: “The difficulties Mark was experiencing became all too clear on March 28, 2022. However, with the events of that day came something of a palpable relief that, having had fringe involvement of the mental health system over the years, there would now be professional, co-ordinated, compassionate and committed support for Mark and his family.
“The reality of that support was that the organisation was too slow to respond, reluctant to be inclusive, displayed an inability to follow their own plans, uncommunicative with us as his family, lacking in resources and had staff that were short of experience making key decisions about his risk.
“The very least Mark deserved was to be afforded the same care and consideration that he showed to all those who had the fortune to know Mark.
“Mark was a genuinely lovely human being, with so much more to offer, and as many others in society deserved far more from the mental health system — a system which is failing both those in our society who are reliant on their help when in crisis but also failing their staff in not giving them the necessary time, resources and skills to help those that are dependent on them.”
Solicitor Gemma Vine, of Ison Harrison, representing the family, added: “This is a case which involved another military veteran who had battled with his mental health, which had been a consequence of his time in service to his country, for many years.
“The internal report from the trust demonstrated that in the short time they were involved in trying to mitigate Mark’s risk to himself, they failed to take reasonable steps to do so. That final decision made on the day before his death to reduce his daily visits was allowed to be made by a less experienced clinical support staff member without any consultation with a more senior member of staff.
“This was a case where Mark showed a willingness to engage with services to get better but then he was not provided with the appropriate level of support that he clearly needed to get him through the significant crisis that he faced.”
Expressing sympathy with Mark’s family and friends, David Muir, group director at the health trust, confirmed the organisation had carried out a serious incident investigation after the veteran’s death.
He said: “As the coroner acknowledged, as a result of this serious incident investigation lessons were learned and changes made to the way we work. This has included improvements to the ways we involve peoples’ families when assessing and planning their care.
“We have appointed carers’ leads to support staff to engage with families and carers, as well as delivering carers awareness training to staff.
“An audit is also now conducted every week to ensure that families and carers are involved, wherever possible, in discussions around reducing risk and helping to keep people safe.”
- If you have been affected by any issues raised in this story, you can talk to the Samaritans. Call 116 123.
