Tragic suicide prompts review into patient care

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Tuesday, October 27, 2009
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This is Kent

MENTAL health bosses are reviewing patient care following the death of a Tonbridge man.

Keith Bowern, 44, faced a 12-mile walk to his Croft Close home with just £2 in his pocket after being released from a Maidstone clinic on December 30 last year.

  1. <P>HOME LEAVE: Keith Bowern was sent home with no house key</P>

    HOME LEAVE: Keith Bowern was sent home with no house key

He later committed suicide.

His death was labelled "tragic and very, very sad" by coroner Roger Sykes at an inquest at County Hall in Maidstone on Tuesday.

Mr Bowern was found hanging from a fence near Barming Railway Station after being released from mental health assessment unit Priority House, in Maidstone, the day before.

He had been there since being sectioned on November 15, for Obsessive Compulsive Personality Disorder in the context of depression, and continued to stay there after he was taken off section on December 8.

The inquest heard how staff at Priority House, including Mr Bowern's doctor, his primary nurse, the ward team leader and the nurse who facilitated his departure had seen no change in his condition since he was admitted for suicidal thoughts.

Mr Bowen's doctor Matthew Debenham stuck by the team's decision to let Mr Bowern on home leave.

He said: "I think we made the right decision but it was not the outcome we would have wanted.

"In hindsight, I think in leaving hospital, that emotional distress would have spiralled and before when suicide was a potential way out it became a reality."

The court heard how Mr Bowern had left the hospital at 3.30pm on December 29 without his parents' knowledge with no phone, house key or transport and only £2 on him.

Veronica Bartholomew, who was in charge of facilitating Mr Bowern's departure, made it clear he did not want his parents to be informed of his departure and she said she had a duty to maintain his confidentiality.

Representing the hospital, John Sheath confirmed that Mr Bowern was an informal patient at the time of his departure and the hospital could not lawfully detain him.

Mrs Bartholomew said Mr Bowern had planned to either get the bus or walk home.

Coroner Mr Sykes asked Mrs Bartholomew if she was aware of the geographical distance from Maidstone to Tonbridge and despite it being more than 11 miles she said: "I thought it was a reasonable distance."

Despite Mr Bowern only having £2 on him, Mrs Bartholomew believed he had £3.50, which she had thought was enough for the bus home.

"I didn't think it was necessary to stop him leaving," she said.

Alice Nash, who was representing Mr Bowern's parents Fred and Josephine Bowern, asked if Mrs Bartholomew had asked if he had been carrying a house key.

She said she had not checked and had assumed he would have had one.

Speaking on behalf of the West Kent NHS and Social Care Trust, Jane Mepham said many changes had been made since Mr Bowern's death, including an action plan of improvements.

She said the trust would be looking at strengthening the links between patients and primary nurses, regular reviews and monthly file audits.

Mr Sykes said although he would agree cause of death was suspension and was satisfied his death was the outcome of intention on his part, he would not return a verdict until he had thought through all the evidence.

Speaking after the inquest his father said: "We knew what the result would be.

"We just hope some of the changes will mean some other poor devil doesn't have to go through what we have gone through. We just can't get over it."

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  • Profile image for This is Kent

    by Roy Everitt, Tonbridge

    Tuesday, November 17 2009, 12:28PM

    “I would firstly like to offer my sincere condolences to the parents of Keith Bowern.


    On reading the report of the inquest into the death of Keith Bowern in the Tonbridge Courier I cannot help but feel very angry!

    It cannot be right can it that a psychiatric patient experiencing suicidal thoughts, recently under section is allowed to discharge himself at 3.30pm, December 29th, 12 miles from home, no house key, no lift home, no one informed, with just £2 in his pocket? His tragic demise will no doubt haunt his parents the rest of their lives.



    At the inquest into his death, Psychiatrist Matthew Debenham is said to have "stuck by the teams decision to let Mr Bowern on home leave" Why's that Dr Debenham? surely if Keith Bowern was sectioned under the mental health act on November 15 he must have been considered then to be a danger to himself and we know that his condition did not improve as:
    "The inquest heard how staff at Priority House, including Mr Bowern's doctor, his primary nurse, the ward team leader and the nurse who facilitated his departure had seen no change in his condition since he was admitted for suicidal thoughts."
    If the care team saw "no change in his condition since he was admitted for suicidal thoughts" why was he then allowed to walk out of hospital at 3.30pm, December 29th, 12 miles from home, no house key, no lift home, no one informed, with just £2 in his pocket? Come on Dr Debenham surely you must be an intelligent man so surely you can see the glaring anomally here? Either you were wrong to detain Mr Bowern in hospital in the first place, (wrongful inprisonment) or you were wrong to discharge him, (clinical neglect) the two cannot be correct at the same time can they!?



    "Representing the hospital, John Sheath confirmed that Mr Bowern was an informal patient at the time of his departure and the hospital could not lawfully detain him." Oh really? Mmmmmmmmm very interesting!!!?? Right OK So WHY if, (as we have already heard) there was "no change in his condition since he was admitted for suicidal thoughts" did the Hospital not renew his section at the point of Mr Bowern wanting to leave? I assume you have heard of sectioning under the mental health act? Of course you must have because Mr Bowern was under section between November 15 and December 8.



    At the inquest Veronica Bartholomew who was in charge of facilitating Mr Bowern's departure said: "I did not think it nescesary to stop him leaving". Why? I thought "the nurse who facilitated his departure had seen no change in his condition since he was admitted for suicidal thoughts" But DESPITE this you thought it ok just to let him go did you? Why's that then? Are you his doctor? Or am I missing something here? Perhaps we don't need doctors in psychiatric hospitals anymore?!



    "Alice Nash, who was representing Mr Bowern's parents Fred and Josephine Bowern, asked if Mrs Bartholomew had asked if he had been carrying a house key.

    She said she had not checked and had assumed he would have had one."



    WAY TO GO VERONICA!!!



    I'm sorry Veronica Bartholomew your Inquest evidence does not add up or make any sense.

    You have clearly failed to meet your responsibility of care for Keith Bowern and as such you should be held directly to account.

    Dr Matthew Debenham why do you stick by the decision to discharge Keith Bowern when any imbecile can see it was clearly wrong. Aren't you just trying to cover up and protect Veronica Bartholomew?



    The Health Authority have clearly admitted to liability why else would Jane Mepham speaking on behalf of the West Kent NHS and Social Care Trust say: "many changes had been made since Mr Bowern's death, including an action plan of improvements.

    She said the trust would be looking at strengthening the links between patients and primary nurses, regular reviews and monthly file audits."

    Hello!? shouldn't all this have been done already? What kin”

  • Profile image for This is Kent

    by Lillie, Sevenoaks,14

    Monday, November 02 2009, 12:53PM

    “My very sincere condolences.
    I know first hand exactly how the parents feel?its disgusting and just like with my experience its a copout!
    You would think that that if Mr Bowern was suicidal and not well?Upon letting him leave?They would check properly Mr Bowern was capable of getting home safely and that people knew exactly where he was?
    and They should make sure you have someone to take you home or not discharge you?

    If I recall properly?They make sure you have someone to take you home if you have had an operation/baby or had an outpatient treatment that involves medication.Dont they??
    So whats the difference? I ask?

    Additionally,They should tell carers/relatives as a duty to life and care?
    putting aside a small amount of the patients confidentiality as a precuation and because they may not have been thinking clearly,also confused by medication maybe? and there life could be in danger?A very important not to be ever ignored? detail!!

    I know that being suicidal is not a natural thought and after actually knowing someone being unwell, trying it and failing suicide?
    Once better and back into real life?They Think why did I ever do something so silly?and then they regret it after realising what affect it would have on people and relatives if it had been successful and it was just because they were not thinking properly at the time?

    This is not the first time someone has died due to the local gp's and mental health department lack of common sense and care.
    Although I cannot prove in detail.
    but I have heard of a patient a few years back that was released and set fire to herself outside an establishment and died.
    I also have a very close first hand experience of the poor duty and lack of care from the maidstone/kent and sussex ambulance local gp & local mental heath department service.
    Ending up with tragic circumstances to my very dear close relative.
    I am sorry to say this but Mentally ill people are sometimes but not always, seen as a burden and waste of time of resources if the staff cannot find an immediate solution.
    All this dangerous medication can sometimes cause suicides if not monitored strongly.I have first hand experience of a member staff at pembury mental heath dept actually laughing at my relative when they were distressed,scared and not well
    I have also seen other patients obviously not well ? come in to the old pembury mental health unit for repeat medicine then sent out drugged up. to cross busy main roads to walk home?One confused gentleman very nearly got run over?

    I am not a medical proffesional but I was on a care team for my relative at pembury and if it wasnt for me actually stopping
    my relative being double dosed due to the GP not conversing properly with the pembury mental heath doctor as they both had perscribed the same drugs twice?
    I had to actually use the hospitals fax machine to fax a doctor from within the unit to make sure the mistake was rectified immediatley?(which is not my job as a member of the public)
    And the psychiatric doctor during another care team meeting was not up to date on the patients situation and notes, as he said he had not read them?and was more interested in when lunch was?

    Additionally If you have ever been to dryhill park road mental heath unit?It is so dark,drab and dull? its enough to make you feel even more depressed?

    I have actually seen a mother at Pembury.Beg for her son to be taken into the mental heath unit on a visit and was crying to me because she could not cope with him at home and the pembury unit would not help her?
    She was again refused and she was sent home from pembury with her son and more pills??

    I also have repeatedly begged for my relative to be cared for in hospital stating that it wouldnt be long before they would die!! only to be refused?after many weeks of asking and one last desperate attempt to get them to take them to hospital that day as I knew something was really wrong?
    again I was ref”

  • Profile image for This is Kent

    by Sammy Wilkison, Stuuffshire

    Monday, November 02 2009, 12:52PM

    “i am 76 and i think the person above is not understanding what we are saying.. Kids Never do ay?? i AM A MAN`!”

  • Profile image for This is Kent

    by Yamomuy, Devon

    Monday, November 02 2009, 12:49PM

    “i think this is teerible and i would hate to see the school knocked down!
    Everyone GO TO HILLVIEW IT ROCKS!”

  • Profile image for This is Kent

    by s, kent

    Tuesday, October 27 2009, 3:51PM

    “My very sincere condolences.
    I know first hand exactly how the parents feel?its disgusting and just like with my experience its a copout!
    You would think that that if Mr Bowern was suicidal and not well?Upon letting him leave?They would check properly Mr Bowern was capable of getting home safely and that people knew exactly where he was?
    and They should make sure you have someone to take you home or not discharge you?

    If I recall properly?They make sure you have someone to take you home if you have had an operation/baby or had an outpatient treatment that involves medication.Dont they??
    So whats the difference? I ask?

    Additionally,They should tell carers/relatives as a duty to life and care?
    putting aside a small amount of the patients confidentiality as a precuation and because they may not have been thinking clearly,also confused by medication maybe? and there life could be in danger?A very important not to be ever ignored? detail!!

    I know that being suicidal is not a natural thought and after actually knowing someone being unwell, trying it and failing suicide?
    Once better and back into real life?They Think why did I ever do something so silly?and then they regret it after realising what affect it would have on people and relatives if it had been successful and it was just because they were not thinking properly at the time?

    This is not the first time someone has died due to the local gp's and mental health department lack of common sense and care.
    Although I cannot prove in detail.
    but I have heard of a patient a few years back that was released and set fire to herself outside an establishment and died.
    I also have a very close first hand experience of the poor duty and lack of care from the maidstone/kent and sussex ambulance local gp & local mental heath department service.
    Ending up with tragic circumstances to my very dear close relative.
    I am sorry to say this but Mentally ill people are sometimes but not always, seen as a burden and waste of time of resources if the staff cannot find an immediate solution.
    All this dangerous medication can sometimes cause suicides if not monitored strongly.I have first hand experience of a member staff at pembury mental heath dept actually laughing at my relative when they were distressed,scared and not well
    I have also seen other patients obviously not well ? come in to the old pembury mental health unit for repeat medicine then sent out drugged up. to cross busy main roads to walk home?One confused gentleman very nearly got run over?

    I am not a medical proffesional but I was on a care team for my relative at pembury and if it wasnt for me actually stopping
    my relative being double dosed due to the GP not conversing properly with the pembury mental heath doctor as they both had perscribed the same drugs twice?
    I had to actually use the hospitals fax machine to fax a doctor from within the unit to make sure the mistake was rectified immediatley?(which is not my job as a member of the public)
    And the psychiatric doctor during another care team meeting was not up to date on the patients situation and notes, as he said he had not read them?and was more interested in when lunch was?

    Additionally If you have ever been to dryhill park road mental heath unit?It is so dark,drab and dull? its enough to make you feel even more depressed?

    I have actually seen a mother at Pembury.Beg for her son to be taken into the mental heath unit on a visit and was crying to me because she could not cope with him at home and the pembury unit would not help her?
    She was again refused and she was sent home from pembury with her son and more pills??

    I also have repeatedly begged for my relative to be cared for in hospital stating that it wouldnt be long before they would die!! only to be refused?after many weeks of asking and one last desperate attempt to get them to take them to hospital that day as I knew something was really wrong?
    again I w”

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