Neglect 'contributed to patient's suicide'
GoogleNeglect contributed to the death of a man who took his own life after being released from hospital too early, a coroner has said.
James Stewart died on 27 December 2024, the day after leaving the Cumberland Infirmary in Carlisle, run by North Cumbria Integrated Care NHS Foundation Trust (NCIC).
Following an inquest, Robert Cohen, assistant coroner for Cumbria, told NCIC the decision to discharge him was "premature" and action should be taken by the organisation to prevent future deaths.
The trust said it would review the coroner's findings and assess what learning it could take forward.
A report by the coroner showed Stewart, who was 52 at the time, had a history of mental illness and drug and alcohol abuse.
On 21 December he was taken to the hospital and detained under the mental health act after making threats to harm himself.
'Failure to intervene'
Once the detention period expired it was determined he would remain in hospital voluntarily for alcohol detoxification, but a decision was made to discharge him on 26 December.
Cohen's report said: "This was premature: Mr Stewart was still suffering from the symptoms of alcohol withdrawal, had not been reassessed by the psychiatric liaison team, and required ongoing treatment."
The coroner said that as Stewart left the hospital he indicated an intention to end his life but, despite a health care assistant raising concerns, the discharge continued.
The report said the hospital did not consider it necessary to arrange transport for Stewart back to his home in Wales and he checked into a nearby hotel where he attempted to take his life.
He was taken to hospital but had suffered "catastrophic injuries" and died.
Cohen said: "Mr Stewart's death was contributed to by neglect, being the decision to prematurely discharge him and the failure to intervene when concerns were raised as to his safety prior to his discharge."
NCIC must write to the coroner by 10 June detailing action taken or planned to address his concerns.
A spokesperson for the trust said it extended its sympathies to Stewart's family for their loss.
They added: "We will review the coroner's findings and assess what learning we can take forward, in addition to actions that have already taken place."
