“Me and the family kept Jim safe, the only time he wasn’t safe was when he was taken out of my care”
A father-of-three took his own life just 67 minutes after being discharged from a mental health unit where his doctor saw ‘no red flags’, an inquest has heard.
James Hulton sadly died on February 21 this year after he jumped from the bridge at Rayleigh Weir before being hit by a lorry travelling on the A127 below.
The 42-year-old from Benfleet, Essex, died instantly from the multiple traumatic injuries he sustained from the fall.
Just over an hour before Mr Hulton took his own life he was discharged from Basildon Hospital’s mental health assessment unit where he had spent four nights as a voluntary patient.
During a two-day inquest into the father’s death, at Essex Coroner’s Court last week, the court heard how doctors involved in Mr Hulton’s care on the unit felt they made the right decision to discharge him when they did.
Prior to his admission to the mental health unit on February 17 Mr Hulton had been diagnosed with mixed anxiety and depression, whilst he had not previously attempted suicide or self harm he did suffer from suicidal thoughts.
Just two days before he was admitted to the mental health assessment unit, the court heard how Mr Hulton visited Rayleigh Weir to “case the joint”.
But, over the course of his stay on the unit, doctors felt his suicide risk had been reduced enough for him to return home – a decision that cost him his life.
Representing Mr Hulton’s family, Mary Ruck challenged the health professionals involved in his care during the inquest.
Devastated by the loss of Mr Hulton, who they referred to as Jim, partner Amanda, sister Suzanne and father John attended the hearing last Wednesday (December 9) and Thursday (December 10) hoping for clarity on their unanswered questions.
The lorry driver’s account
Tom Hardingham, from the Essex Police Serious Collision Investigation Unit gave evidence via video link.
The court heard how emergency services rushed to the scene at 2.18pm and closed the carriageway in both directions while they investigated.
Sadly, Mr Hulton was confirmed dead at 2.30pm.
Mr Hardingham read aloud some eye witness statements before summarising the findings of the Essex Police investigation.
Referring to the statement provided by the HGV driver, Anthony Patterson, Mr Hardingham said: “He stated he had been driving the vehicle for around one week, and felt comfortable with the features and controls within the vehicle.”
The court heard how he had been a lorry driver for 47 years and, on the day of the fatal collision, he had no driver hours infringements and had been adequately rested.
In the moments before the fatal collision Mr Patterson saw a ‘dark object’ fall to the floor from the bridge at the Rayleigh Weir.
After pulling over he called the emergency services within 30 seconds and remained at the scene until they arrived.
The court later heard how there wasn’t enough time for Mr Patterson to react and avoid the collision.
“He made no attempt to pull himself back”
Multiple witnesses saw James ‘pacing backwards and forwards’ on the bridge in the moments before he jumped.
One witness who described seeing James ‘milling about’ on the bridge was Jason Ward, who was driving on the opposite side of the carriageway at the time of the incident.
Referring to Mr Ward’s statement, Mr Hardingham said: “He thinks this was deliberate as he made no attempt to pull himself back.”
The court also heard from Victoria Brassel, who was allocated as Mr Hulton’s care coordinator in January this year.
Whilst under her care Ms Brassel said: “He expressed a desire for someone to fix him and he hoped for an immediate relief from his thoughts and feelings.”
The court heard how Ms Brassel classed Mr Hulton as being at a high risk of suicide.
Mr Hulton attended various group sessions and therapy to help improve his mood, but the court heard how he did not feel the group sessions were benefiting him.
On the evening of February 17 he agreed to an informal admission to the Basildon mental health assessment unit.
The following day Ms Brassel visited him at the unit.
“Hospital was a place he feared most, so I know he wasn’t comfortable by any means being there,” she said.
Following his voluntary admission, staff on the assessment unit took over his care.
Mr Hulton’s four-night stay on the ward
When Mr Hulton first entered the ward he was under constant observation, but the level of interaction was reduced to checks every 15 minutes on the morning of February 18.
During his time on the ward Mr Hulton displayed no signs of violence or attempts to harm himself, he engaged with other patients and even made friends with another patient.
Dr Agunwamba, one of the doctors involved in Mr Hulton’s care whilst he was on the ward, gave evidence via video link.
She explained how Mr Hulton was taking a number of prescribed medications, including antidepressants, antipsychotics and medication to help improve his sleep.
However the court heard how James had missed up to five or six doses of vortioxetine (an antidepressant) in the two weeks leading up to his death.
Despite this, health professionals did not believe this would have caused or contributed to Mr Hulton’s death.
Dr Agunwamba said: “When I spoke to Mr Hulton he seemed lively and made good eye contact, he said he had been feeling low in mood for a very long time and that his family had been concerned about him.”
According to Dr Agunwamba, Mr Hulton felt his time on the ward helped him to reflect on his difficulties and made him feel better in himself.
But Dr Agunwamba explained how he said he felt “shattered” being away from his children and requested a family visit.
She said: “He told me he was missing his children, and it was the birthday of one of his sons, and that he would really like to visit him, so I agreed he could have a family visit on the ward.
“He told me he had been missing his boys so much and that they had planned to go to Harry Potter World, he was planning to take them there over the weekend.”
The court heard how his partner Amanda took her sons to the unit on both February 18 and February 19, and on both occasions Amanda reported that Mr Hulton was “fidgety and anxious”.
Despite Mr Hulton’s unsettling emotions Dr Agunwamba did not see any ‘red flags’ and he was discharged at 1.11pm.
She said: “He had capacity and full insight.
“His mental state seemed to have stabilised to a certain extent, I felt the risks had minimised enough for me to discharge him.”
“A tragic incident will make you reflect on our process and I think this is no exception”
Dr Blaga Carr, who had been lead consultant on the 20-bed assessment ward since December 2016, also gave evidence via video link. Dr Carr agreed with Dr Agunwamba and said discharging Mr Hulton was “the right decision”.
She said: “Overall the impression was that Mr Hulton had settled very well on the unit and that he had benefited from this ‘time-out’ in hospital.”
Dr Carr, who never met James in person, told the court how there was never a moment during his stay on the unit where staff felt he needed to be detained under the mental health act.
Mary Ruck, representing Mr Hulton’s family, asked Dr Carr: “Based on what you know now on Mr Hulton, his care and matters explained today, do you feel any different?
“The family feel, because he so swiftly acted after his discharge, it’s obvious they feel that he ought not to have been discharged.”
Dr Carr responded: “A tragic incident will make you reflect on our process and I think this is no exception. I think it’s a sad occasion and if I say that we cannot learn anything from that I would be wrong.”
The hearing also heard the trust had reviewed the case, with Principal Clinical Psychologist Rob McCarney saying there was “room for improvement” over communication.
Reading her statement to the court Suzanne described her brother as being “really bright” and said: “He did love family time, he was a great dad, he was a great everything.
“He was a much-loved younger brother, a person who I absolutely adored and did my best to protect.”
Suzanne was aware of his suicidal thoughts as she said he confided in her on several occasions and said she spoke to him around the clock to make sure he was ok.
She said: “We were absolutely terrified of leaving him alone… we were becoming ill.”
When Mr Hulton was on the mental health unit Suzanne would speak to him over the phone and was so concerned by his behaviour and what he was saying that she made several complaints to the trust.
She told the court: “They weren’t treating him as a human being.
“I had been escalating complaints wherever I could, I was pushing like mad, it never ended, it was traumatic.
She added: “We would have done anything we could to make sure he was not discharged.”
Amanda spoke to her partner both over text and on the phone on the morning of his death.
She said: “He asked if I would back him if he was to be discharged on text, but I wanted him to stay in hospital to get better.
“I was conscious that, on one hand, Jim said he felt he was getting better but on the other hand he was downplaying his symptoms.”
Amanda last spoke to him at 11.30am that morning and was unaware he was being discharged that afternoon.
She said: “Later that day I saw there was a message on the work group chat that someone had jumped from the Rayleigh Weir bridge.
“This worried me so I tried to call Jim but there was no answer. I also tried to contact the ward but had no answer.”
If Amanda was told about his discharge she said “there is no way on earth” she would have let him leave the unit alone.
Amanda said: “In my opinion, me and the family kept Jim safe. The only time he wasn’t safe was when he was taken out of my care – to what was meant to be a place of safety – but it was not because that was the only time Jim was ever unsafe.
Area Coroner Lincoln Brookes said the family had done “all they could” to help him and that there was “no egregious failure” in allowing Mr Hulton’s discharge. He said it was not possible to say with certainty if the family being consulted beforehand could have changed the outcome.
Reading the verdict, Mr Brookes said: “It was accepted that it would have been more prudent to have informed his family of the intent to discharge. Thus, enabling them to inform the unit of their views against discharge, or at least safely accompanying him home.”
“We hope that no other family will find themselves in the same circumstances”
In a statement following the inquest, Mr Hulton’s family said: “Jim was a much loved partner, daddy of three, son, brother and uncle and the family have been devastated by his death.
“We have been pleased to learn more about his care through the article two inquest process.
“We hope that no other family will find themselves in the same circumstances and will not have to endure our pain and sense of loss.”