Failures over supervision of a high risk patient who walked out of Solihull Hospital and hung himself contributed to his death, a jury has found.
Fifty-three-year-old Thomas Sidwell should have had one-to-one supervision but went missing from ward 19 on July 13 last year and was found in woodland seven weeks later.
A jury at an inquest in Birmingham concluded that Mr Sidwell died as a result of suicide contributed to by neglect.
They said there had been a lack of communication regarding his mental state and a lack of planning over his one-to-one cover.
They also found there had been a lack of communication as to who was watching Mr Sidwell and a failure to adhere to a management plan.
However Coroner Louise Hunt said she would not be making any recommendations to the trust running the hospital after hearing about an action plan and the number of steps that had already been put in place following Mr Sidwell’s death.
She asked family members to “remember Mr Sidwell as he was rather than how he had suffered in the last few months before he died.”
The inquest had heard earlier Mr Sidwell, a grandfather, was admitted to the hospital on July 8 after taking an overdose and that he was on ward 19 awaiting a transfer to a mental health ward.
His sister, Carol Robinson, said he became depressed after breaking up with his partner of 33 years.
Mrs Robinson said her brother had tried to harm himself before and was agitated and confused when he was admitted to hospital.
The mental health nurse appointed to supervise him on the morning he disappeared did not turn up for their shift.
Heart of England NHS Foundation Trust, which covers Solihull Hospital , has a policy which states patients considered at high risk of self harm should not be left unsupervised at any time.
She told the inquest jury that she knew of Mr Sidwell’s supervision requirements but allowed him to go to the toilet on his own.
She said she watched him go into the toilet but the next thing she knew he had left the ward.
The grand-father-of-five was found by a dog walker in woodland in Catherine-de-Barnes.