Suffolk mental health trust "time delay" contributed to death
A review of CCTV footage would have allowed the search for a man who later hanged himself to start sooner, a coroner's report has revealed.
Matthew Arkle, 37, was given an hour's unescorted leave from a NHS mental health unit in Bury St Edmunds, Suffolk, on 4 April 2017.
Cameras confirmed he left 90 minutes earlier than the time staff had written on notes - delaying a police search.
Senior coroner Nigel Parsley said the delay "contributed to Matthew's death".
Charity worker Mr Arkle, who had schizophrenia, was admitted voluntarily to Wedgewood House on 17 February 2017 after a second overdose of medication.
Mr Arkle was found hanged in woodland two days later and an inquest in 2018 concluded it was suicide.
The unit, on the West Suffolk Hospital site, is run by the Norfolk and Suffolk NHS Foundation Trust (NSFT),
He was permitted the leave, but the coroner heard his family had specifically asked for him not to be allowed out.
However, staff working on the ward when he left were not aware of this, the post-inquest report said, and there was a "delay in noticing, reacting and reporting" his disappearance.
The Prevention of Future Deaths report said activity on the ward was "extremely high" and the note of the time Mr Arkle left - 19:00 BST- was "an approximation" by staff.
A nearby garage's CCTV cameras, viewed after his death, showed Mr Arkle leaving the unit at 17:30, meaning the alarm should have been raised if he had not returned by 18:30.
When he was reported missing to Suffolk Police at 21:06, officers were not told of his serious condition and did not have a recent photograph of him for their search, the report said.
There was no policy for staff to review footage from CCTV cameras on the hospital site, which could have established an "accurate time and possibly direction of travel".
Mr Parsley's report, sent to the NSFT's chief executive, concluded "action should be taken to prevent future deaths and I believe you or your organisation have the power to take such action".
In a statement, the family's solicitor, Tim Deeming, said they "would like reassurance that no other patient has left the unit in preventable circumstances since Matty's death so that we know that effective lessons have been learnt from the tragic events and that there is a clear legacy for him".
The Trust said it had carried out "a detailed review to learn as much as possible from Matty's passing and to implement positive improvements in services".