‘The system failed him in the most catastrophic way’ – Father’s anger at mental health over son’s suicide
07:00 17 October 2013
A grieving father has hit out at a mental health trust for letting down his son in the days before he killed himself.
‘Decisions were based on expertise’ - trust response
Roz Brooks, director of nursing and patient safety at Norfolk and Suffolk NHS Foundation Trust, said: “I would like to extend our sincerest condolences to Michael Knight’s family.
“We recognise the tragedy and loss of all those affected by his death including the staff involved in his care. These members of staff made decisions about Michael’s care based on their clinical knowledge and expertise.
“By following the code of practice which supports the Mental Health Act, Michael could not be compulsorily admitted or detained against his wishes.
“Therefore, he maintained the right to choose his treatment options including an informal admission.”
Since April 1, NSFT has operated a total of 355 mental health beds in Norfolk, of which 173 are for acute admissions for sectionings under the Mental Health Act.
Following Mr Knight’s death a serious investigation report was compiled, which found that staff followed the “right pathways”. It said an acute bed would have been found for Mr Knight if he had been sectioned.
A specialist pilot scheme aimed at the “problem” age of 18 to 25-year-old has since been made permanent and staff have been told to obtain mobile phone numbers for family of patients, so that they can be updated quickly if situations change, such as beds becoming available.
Andrew Knight pleaded with mental health workers to section his son, Michael, after he had made two suicide bids last summer.
The 20-year-old eventually agreed to be admitted voluntarily into hospital on August 28, only to find out that no bed was available in Norfolk, where he wanted to stay, and he would have to wait until the next day.
When mental health workers told him a bed had become free that evening, he asked to wait until the following the day as planned, but confronted the prospect of having to “finally face his demons”, his father said, and hanged himself.
Psychiatrists assessed Mr Knight on August 26 and again on August 28, both times deciding against sectioning him, though they persuaded him to be admitted voluntarily to calm his increasingly erratic behaviour.
‘The system failed Michael in the most catastrophic way’
Michael Knight’s father, Andrew, spoke out following the verdict, holding the mental health trust responsible for the tragedy and paying tribute to his son.
“The way I see it is that they are responsible. Michael was in their care,” he said.
“Myself, my family and anybody else can see that the system failed us - and it failed Michael, in the most catastrophic way.
“I pleaded with them to section him. If you look at the way he was behaving, it was a crisis, and a bed would have been found for him and made available.
“I asked them: does he have to commit suicide before you will take this seriously?
“And I asked the doctor if he was going to take responsibility if he succeeded.
“Even we were fooled at the last minute by Michael’s condition. We felt a bit of relief, only to come back and find Michael dead.”
Mr Knight described his son as a kind person, with a strong artistic streak.
“He was a very talented artist, and had just won a scholarship to study art in Aberdeen.
“He had a good heart in him, he was a lovely chap. All the kids loved him - he was just that kind of person. Everybody loved him.”
At an inquest in Norwich yesterday, coroner Jacqueline Lake said the indecision over his admission had made Mr Knight’s mental health situation worse, concluding that he “took his own life while the balance of his mind was disturbed and while in the care of the mental health services.”
She said: “The tragedy in this case is the fact that, after having gained Michael’s agreement to accept voluntary inpatient care, a bed was not then available.
“I’m of the view that the situation was then exacerbated by the to-ing and fro-ing which then took place with regard to a bed becoming free, but only for a very short period of time before it was then unavailable.”
Mr Knight had worried his parents with his unpredictable behaviour in the months before his death, which included a drunken suicide attempt while living in Aberdeen, and one occasion when he threatened to set himself alight.
He moved from Scotland, where he had been living with his mother, to live with his father in Newton Street, Newton St Faith, in July 2012.
Struggling to deal with a relationship break-up, he invented stories of being ill and of being pursued by a gang in Scotland.
In assessments psychiatrists said Mr Knight did not show signs of depressive or psychotic behaviour, though he was prescribed medication to calm his mood.
Acting consultant psychiatrist Dr Ali Rahim Abdul told the inquest Mr Knight had not declared any intention to kill himself, but that admission to hospital would not have solved his problems.
“We didn’t have clear, easy solution to it,” he said. “The risk would have remained if he had come into hospital.”