Lee West inquest: Hospital failed to keep its patient safe

Lee West was just 20 when he was hit by two cars on the A47 near Postwick while walking in the middle of the dual carriageway.

Two hours earlier, he absconded from Southern Hill Hospital, where had been sectioned under the mental health act for his own safety.

He left the Mundesley facility, 22 miles away from the place of his death, after "tailgating" behind a nurse who had opened a secured gate from the hospital courtyard.

At the end of an inquest into his death, a jury of seven women and four men concluded that he had been failed by the hospital - and this had contributed to his death.

Lee West (Image: Lee West Snr) After deliberating for more than seven hours, the jury gave a narrative conclusion into the circumstances of Mr West's death. 

It stated: "Lee West died as a result of traumatic injuries he sustained after being hit by two vehicles while he was deliberately walking in the middle of a dual carriageway.

"His intent at the time is unknown due to his mental health issues.

"Failure to keep Lee West safe while he was sectioned under the mental health act contributed to his death."

Lee West Snr outside Norfolk Coroner's Court (Image: Newsquest) 'My son was let down'

Following the inquest, Mr West's father - who attended in person at every stage of the inquest - said his family had been "let down" by the hospital.

He said: "The failure of the hospital is clear to see and I think the attitude towards what happened was a bit blasé.

"I think there was a complete failure to keep my son safe, not only when they let him abscond but the way this was responded to. Had they been more proactive I think the outcome could have been changed.

"The impact this has had on my family has been catastrophic and it is going to be many, many years for us to recover."

Mr West Snr described his son as a "beautiful young man" who loved gaming, computers and going to the gym.

He said he was "thick as thieves" with his two siblings, 22-year-old Anita and 16-year-old Luke, who both missed him dearly.

He added that he is now planning to make formal complaints against the hospital and will be pursuing the case through civil courts.

He said: "It is going to be a battle, but I will seek justice for my son - he deserves that."

An avoidable tragedy

Southern Hill Hospital (Image: Geraldine Scott) During the inquest, which concluded on its eighth day, it was heard that Mr West had left the hospital after managing to slip past ward manager Jennifer Dean in the courtyard, after she had opened the gate.

While she was giving evidence, Ms Dean said that she had called for a second member of staff to replace her in the courtyard so she could leave - but had opened the gate before they arrived.

She accepted that this was against the site's policy - and that she should have waited for the colleague to arrive.

She also accepted that she should also have been more aware of her surroundings when she unlocked the gate - checking better whether Mr West had snuck behind her.

The court heard that since the tragedy, the nurse had gone through stricter training and that security measures had been ramped up - including installing mirrors around the gate.

The court also heard that throughout his two-week stay at the hospital, there had been several warning signs about Mr West's state of mind.

Among these, the aspiring DJ self-harmed on a number of occasions - although his injuries were described by staff as "superficial" - and had made comments about wanting to "do a runner".

And following his departure from the hospital, fellow patients told staff that he had commented about ending his life if he could get away from the hospital.

His care plan during his stay stated that he would need to be observed by staff four times every hour. 

It also emerged during the inquest that the very reason Mr West, from Colchester, was being treated in Southern Hill was a lack of available beds in Essex after he was sectioned.

Samantha Goward, area coroner for Norfolk (Image: Denise Bradley)

Area coroner Samantha Goward said: "The hospital's director agreed with evidence that the gate should not have been unlocked without a second member of staff there.

"She also accepted there was a breakdown in communication which delayed the police being called."

Following the conclusion of the inquest, Southern Hill Hospital refused to comment on the case.

Analysis

Lee West's death was a tragedy, and heartbreakingly one that was very much avoidable.

Throughout the course of his inquest, evidence was heard of how he was able to abscond from hospital, travel across the county and ultimately, meet his tragic end on the A47.

The 20-year-old aspiring DJ's loss has left a gaping void in his family and a form of grief they have to live with for the rest of their lives.

But the circumstances surrounding the death is what makes it such a heartbreaking tale to tell - and one that is devastating for everybody involved.

It was accepted that he clearly should not have been put in a position where he was able to escape from the hospital.

The very reason he ended up there was so he could be kept safe, but on that fateful day, he was not.

It is so important that lessons are learned from this case, or else history may well repeat itself.

While our sympathies are firmly with Mr West's families, they are also with the individual whose error proved the catalyst for this tragedy - she has got to live with this knowledge too.

But it is very clear that this was a systemic failure, the responsibility does not solely lie with the nurse whose split-second lapse in concentration allowed Mr West to abscond.

It is vitally important not to forget that the very reason Mr West was being treated at Southern Hill is there were no available beds for him in Essex, where he lived.

This is sadly a trend we have seen far to often locally too - people at their most vulnerable being sent miles from home.

It is so important for people not to be dragged away from their local support networks and yet we still constantly hear of this.

Clearly Mr West was led down by the staff at the hospital that night, but he was also let down by a failing mental health system that for too long has not been taken seriously enough.

The state of the mental health system is a crisis - it has to be treated as such.