PERFORMANCE: Sussex Partnership Foundation Trust has said it “sincerely regrets” the shortcomings in the care provided to a man with mental health problems who was found dead at his home last year.

A jury inquest into the death of Patrick Whiting concluded on 27 February. The jury returned a verdict of “death from hanging whilst suffering a mental health illness”.

Mr Whiting was found dead at his home in May 2012. At the time he was receiving support from the Brighton Crisis Resolution and Home Treatment Team, following discharge from the trust’s Woodlands Centre for Acute Care in St Leonards on Sea.

In March 2012, he had attempted to take his own life by jumping onto electrified railway tracks, but survived the fall and was admitted to hospital. He was “sectioned” under the Mental Health Act and later transferred to the secure unit run by Sussex Partnership in St Leonards.

Mr Whiting was deemed to be in a sufficiently stable mental state to be released from the unit in May and sent home. But three days later his twin brother Andrew found him hanging in his bedroom.

Rachel Heelis, of Attwaters Jameson Hill Solicitors, who represented the deceased’s brother, said: “The inquest heard about a number of disturbing aspects to this tragic case, which had led the NHS Trust concerned to issue an apology to Patrick Whiting’s family.”

For example, she noted that Andrew Whiting had previously worked as a mental health nurse with the Sussex Partnership and acted as his brother’s carer, but was “neither consulted nor informed” about his twin’s progress in the weeks before his death.

She said: “We found that managers had made decisions to alter this vulnerable patient’s treatment without consulting clinicians and called him to a meeting about this without telling his treatment team.”

Ms Heelis added: “Ambiguity surrounded whether Patrick Whiting was on leave or being discharged. Either way, the home treatment team had grave concerns that he had left hospital too soon.

“It is right that the NHS trust has acknowledged significant failings and is at last making appropriate changes, though sadly too late for Patrick.”

She highlighted “various issues” that contributed to Mr Whiting’s “deteriorating mental health and untimely death”, including an inadequate care plan, lack of communication, administrative shortcomings and poor monitoring of medication.

Dr Shakil Malik, clinical director for adult mental health services at Sussex Partnership, said: “We were deeply saddened by Mr Whiting’s tragic death and continue to extend our sympathy to his family.

“We have acknowledged that errors were made and we accept the jury’s findings that there were a number of shortcomings. We have apologised unreservedly to Mr Whiting’s family.

Since Mr Whiting’s death, the trust said it had made a number of changes to its ways of working.

These included a new policy to ensure people with inpatient stays of longer than four weeks have trial leave before they are discharged, updated protocols to improve the involvement of families in decisions about care and to improve staff communication with carers.