“Neglected mental health escape” : Neglect at Mental Health Hospital Contributes to Death of Jamie Roe

Neglect by mental health hospital staff has been blamed for the death of a man who escaped from the facility despite being considered a high-risk absconder. Jamie Roe, a 20-year-old patient at Fulbourn Hospital near Cambridge, managed to escape during a family visit and tragically died in 2021. A jury investigating the incident concluded that there was insufficient staffing and inadequate risk assessment in place to ensure a safe visit.

During the inquest held at Peterborough Town Hall, Mr. Roe’s mother, Wendy Setterfield, described her son as a non-judgmental individual who never spoke ill of others. The jury revealed that Mr. Roe had been seen by a mental health team at an accident and emergency department in Nottingham, where he was a student, after displaying signs of psychosis on November 13th of that year. His flatmates had called for help, reporting his bizarre behavior and self-harm tendencies.

Upon admission to Fulbourn Hospital’s Mulberry 2 ward, it was determined that Mr. Roe was a high-risk absconder, leading to his placement in a unit with an airlock system as a precaution. However, during the visit from his mother, the family room within the airlock was used, compromising the secure system. The jury found that staff did not have sufficient time to review Mr. Roe’s complete patient notes and understand the full extent of his absconsion risk due to understaffing.

On the day of the visit, the ward was short-staffed, and the nurse in charge admitted that it would not have been safe for Mr. Roe to be in the family room within the compromised airlock. Tragically, he managed to escape when a staff member opened the door, and he was later struck by a lorry.

The jury’s findings were clear: there was evidence of neglect that directly contributed to Mr. Roe’s death. The Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) expressed its condolences to the family and friends of the deceased and fully accepted the jury’s findings and the coroner’s recommendations. The trust has implemented several changes and improvements to enhance patient safety, including better risk training for nursing staff, updated patient observation levels, and revised protocols for family visits.

Mr. Roe’s family described him as gentle and sweet-natured, emphasizing that they do not blame any individuals but believe that the system as a whole failed him. They hope that permanent lessons will be learned from his tragic death.