“The decision to rescind the section on 17.09.2020 was made: a”

The coroner’s concerns

1. The decision to rescind the section on 17.09.2020 was made: a. b. by a responsible clinician who had been in this role for only two weeks. his family were not involved in the decision at all and only became aware of it after it had been made. no formalised assessment of his mental capacity was made prior to the decisions. his care plan had not been updated. the pressure on bed availability in the Newsam Centre may have influenced the decision. c. d. e. 2. Mr Bastock's treatment in the Newsam Centre lacked continuity. The 1 3. a) b) c) d) e) f) 6 responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including: Mr Bastock left the ward on occasions and once did not return until 5am. On his return, there was no recorded evaluation of his situation and what action was required from the team treating him. A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded. Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered. Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section. When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales).

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2021-0365

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0