A Coroner found it “astonishing” a suicidal psychiatric patient who brushed past City commuters and threw himself in front of a tube train was allowed to roam free by doctors at a flagship emergency ward.
Jobless Anthony Simkin, 46, of Cornwallis Court, Lansdowne Green, South Lambeth triggered an internal probe by South London and Maudsley NHS foundation Trust who admit mistakes were made.
Mr Simkin suffered fatal multiple injuries at Monument Underground Station on June 24 last year when struck by a westbound District Line tube train.
He simply walked out of the Trust’s Luther King Ward in Landor Road, Stockwell after bungling psychiatrists approved the patient for unescorted leave.
City of London Coroner’s Court heard depressed heroin addict Mr Simkin had previously overdosed on prescription drugs and slashed his wrists three weeks before his death, requiring a blood transfusion at St. Thomas’s Hospital.
“That does seem rather astonishing,” said Coroner Paul Matthews. “He had made three attempts on his life before this.
“They were not cries for help. They were serious attempts on his life. You don’t throw yourself in front of a train if you are not serious.”
Mr Simkin had been sectioned under the Mental Health Act after the wrist-slashing incident and housed at Luther King Ward a Lambeth residents-only unit which prides itself on being a : “Safe and therapeutic environment for clients.”
Trust supervisor Claudia Fullalove told the Tuesday hearing an internal enquiry was launched to investigate errors in the case and changes have been made to their procedures.
“I think there were a number of missed opportunities during his period of care,” she admitted. “Mr Simkin seemed to fall below the radar. They underestimated his level of risk.”
She conceded there was no in-depth risk assessment within seventy-two hours of Mr Simkin being admitted – flouting Luther King Ward’s own procedures.
“They felt he did not present with significant risk. The doctors and nurses believed he was showing signs of improvement,” added the supervisor.
Community mental health nurse Jane Eastaway, based at a different Lambeth clinic the patient regularly visited, had urged the sectioning of Mr Simkin, but felt a mere three weeks was way too early to allow him out.
“I thought it was really soon,” she told the inquest. “I felt anxious he was getting unescorted leave before his medical improvement.”
However, she did not make a fuss. “It is difficult because there is a consultant above me who has made the decision. I did not directly challenge anyone on that.”
The inquest was adjourned until a future date so the psychiatrists who allowed Mr Simkin’s unescorted leave can be called to give evidence.
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