A Lancaster man’s early discharge from hospital “significantly contributed to a worsening of his mental health” just days before he committed suicide, an inquest heard.
Former Carnforth High School pupil Sam Rogerson, 26, who lived at Willow Lane Rehabilitation Unit, was found hanged in woods nearby on March 5 2017.
At an inquest at Lancaster Castle on March 20, Lancashire Area Coroner Richard Taylor said he had concerns about Sam’s discharge from Blackburn Hospital on February 17 2017, where he had been admitted after an overdose and “escalating self harm”.
Sam’s mum Wendy Rogerson said after the inquest that she felt no closure and questioned why she wasn’t more involved in his care in the weeks leading up to his death, adding: “We put our trust in the NHS that they were doing the right thing for him, but they were not.”
An internal investigation by Lancashire Care NHS Foundation Trust, which provides mental health services across the county, found that “treatment would have been the most appropriate option”, but instead Sam was discharged early and returned to the 11-bed Willow Lane rehabilitation unit, where he had lived since 2014.
The unit’s manager Christine Haggan told the inquest that staff had repeatedly expressed concerns about their ability to look after him.
She said: “He was doing really well, engaging in all his activities, he was sociable, but also quite isolated at times.
“He loved cooking, being out in the garden, baking cakes. In some ways he was ready to move on, but he didn’t manage change very well.
“We had regular reviews about whether he was ready to move on, there was accommodation found, but he started self harming and had low mood. Sam would say it was because of the move.”
She also told the inquest that Sam didn’t want to get his mum involved, and “didn’t want her to see the scars”.
Mr Taylor questioned why Mrs Rogerson wasn’t more involved in Sam’s care, given the unit had arranged for more staff to be present at the unit following his discharge.
Mrs Haggan said: “Sam was adamant that he didn’t want his mum involved, and we have to protect his rights.”
Sam was diagnosed with schizophrenia in 2009, and had himself expressed concern about returning to Willow Lane, and would be better off in a psychiatric hospital.
Ken Levins, from Lancashire Care NHS Trust, conducted an internal investigation and found that “treatment would have been the most appropriate option”, and that Sam was discharged due to a “judgement call on the day”.
He said the discharge meeting should have been postponed, but that the process that was taken “was in the standard that we expect”.
Sam was discharged from the hospital despite having severe self-inflicted lacerations to his arms, and being found with a ligature in his room just days before.
The Lancaster Guardian has seen a “Learning Review” produced by the trust following Sam’s death which recommended among other things that “any resident under Specialist Rehabilitation Services within Lancashire Care should not reside or be discharged to specialist rehabilitation accommodation if they are in an acute phase of illness, presenting with high risk to self or others, detained under the Mental Health Act and cannot manage their own safety”.
Coroner Mr Taylor said: “My main concern as I’ve listened to the witnesses has been the discharge from Blackburn Hospital on February 17.
“Given his original diagnosis and escalating self harm, and given Willow Lane expressed well documented concerns about their ability to look after him, it seems a little surprising that he was discharged when he was.
“He was at known risk of self harm. His early discharge from an assessment ward rather than receiving treatment for his condition, and the underlying anxiety, significantly contributed to a worsening of his mental health.”
He recorded a verdict of suicide.
Following his death last year, a JustGiving page was set up in Sam’s memory.
More than £1,350 was raised and dontated to Lancaster food growing project Fork To Fork, where Sam enjoyed spending time and helping out.