Hospital failing highlighted after man (38) killed himself

A hospital failed to manage “an obvious risk of self-harm” in a patient who fatally hanged himself, an inquest jury decided.


Jonathan Keith Davies (38) a warehouseman from Manchester, was found hanging in his room by staff at Kemple View Hospital, Longsight Road, Langho, in September 2013 and died three days later at Royal Blackburn Hospital.

The inquest at Ribble Valley Borough Council Chamber, Clitheroe, heard nearly three weeks of evidence from staff, managers and mental health experts, and the jury was taken to visit the ward.

Mr Davies had been sent to Kemple View by a crown court order under the Mental Health Act, and was under Stage Two observation. Staff told the inquest he had made no previous attempts at self-harm while he was there.

Mr Davies was found hanging in his room on a Sunday in September 2013.

He had twisted a long-sleeved top into a ligature and attached it to a bracket on an overhead locker.

Staff told how on the day of the incident they found Mr Davies hanging, took him down and administered chest compression and defibrillation before paramedics took him to hospital.

Cause of death was cerebral hypoxia due to hanging.

The jury presented a written verdict to The Coroner, Mr Michael Singleton, stating that Mr Davies deliberately chose to suspend himself, but it was inconclusive whether he intended to take his own life.

The jury believed the overhead bracket was a self-harm risk that had not been appropriately managed.

“Failure to manage an obvious risk of self-harm contributed to the outcome,” their verdict stated.

After the inquest, Partnerships in Care released a statement saying:

“All staff at Kemple View were deeply saddened by the death of Mr Jonathan Davies at Royal Blackburn Hospital on 18 September 2013.

“The inquest, which concluded today, found that Mr Davies died as a result of his suspending himself within his room on 15 September 2013.

We extend our sympathy to Mr Davies’ family and friends.

“We place the utmost importance on patient safety. Following this incident, we have taken further steps to reinforce environmental risk assessment and security at Kemple View. Among steps we have taken is that patient rooms are visited and lockers are checked regularly throughout every day.”