James Booth

Priory, Altrincham. There were no local NHS acute beds available. The plan was for repatriation at the earliest opportunity. The diagnosis was anxious avoidant personality disorder, with severe depression and some symptoms of psychosis. On 14th August 2020 James made an attempt to abscond. James made a number of references to his wish to escape and to end his life. James was on Level 2 observations (2 per hour) from 30th July 2020 Period from 01.10.20 to James absconding on 07.10.20. 01.10.20: James had to be persuaded to come back on to the ward on return from breakfast at the Grange (off Ward). This matter was noted on the Ward Round later that morning. A Risk Assessment was carried as per routine for the Ward Round. 04.10.20: James made an attempt to push past a member of staff when they were coming through the main door to the Ward. This event was noted in the Care Notes with the note “wanted to run away and commit suicide”. It was not recorded in the Datix system. The Responsible Clinician was not informed. No risk assessment was carried out. The event was recorded on the handover sheet from the 04.10 Dayshift (DS) to the 04.10 Nightshift (NS) within the Clinical Risk section. It was not noted in box ‘Incidents in last 7 days’. The event was not recorded in the Clinical Risk section of the 04.10 NS to the 05.10 DS. It was not noted in the box Incidents in last 7 days’, and did not appear in that Box for any of the subsequent handovers. 05.10.20 At around breakfast time James was seen walking up the main drive of the hospital towards the main entrance. When James realised he had been seen he ran away out of the grounds but was eventually caught up with and brought back to the Ward. He would not say how he escaped from the Ward but from his position when first seen it was likely to have been from the garden area of the Ward. This event was noted in the Care Notes. It was recorded in the Datix system – but the report was closed with ‘no lessons to be learned’. The Responsible Clinician was not informed. No risk assessment was carried out. The event was recorded on the handover sheet from the 05.10 DS to the 05.10 NS within the Clinical Risk section. It was not noted in box ‘Incidents in last 7 days’. The event was not recorded in the Clinical Risk section of the 05.10 NS to the 06 DS. It was not noted in the box Incidents in last 7 days’, and did not appear in that Box for any of the subsequent handovers. 06.10.20 During an escorted walk within the hospital grounds James made attempts to divert the walk away from the planned route, one of them towards the adjoining golf club. When near to the main entrance James tried to run away but staff blocked his way. This event was noted in the Care Notes. It was not recorded in the Datix system. The Responsible Clinician was not informed. No risk assessment was carried out. The event was recorded on the handover sheet from the 06.10 DS to the 06.10 NS within the Clinical Risk section. It was not noted in box ‘Incidents in last 7 days’. The event was not recorded in the Clinical Risk section of the 06.10 NS to the 07.10 DS. It was not noted in the box Incidents in last 7 days’. 07.10.20 James absconded at around 13.15 to 13.30 hrs. He was last seen in the vicinity of the door leading out on the garden. The probable route of escape was over the garden fencing. 14.10.20 James’ body was found as above.

8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, Mr Booth’s family, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated this 17th July 2022 Andrew Bridgman HM Assistant Coroner