Trust’s failure to involve family in risk & safety planning possibly contributed to Mark Rodhouse’s death

27 January 2023

Lily Lewis

The inquest into the death of Mark Rodhouse concluded on Wednesday 25 January 2023 following two days of evidence heard by Margaret Taylor, Assistant Coroner for Cumbria.

Ms Taylor concluded that Mark, who was a military veteran, died from suicide. She further found that there was a failure by the Trust to involve Mark’s wife in risk and care planning and consequently she was unaware of information that may have changed the nature of this risk and this failure possibly contributed to his death.

During the course of the inquest, the Coroner heard evidence from witnesses from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust in relation to Mark’s mental health care between March and April 2022 when he had a significant mental health crisis.

During the evidence, the following issues were highlighted:

  • That Mark having been medically discharged from the Army in 2005, due to a number of physical factors but also his mental health, continued to battle his anxiety until his problems worsened following a significant crisis in early 2022;
  • That there was poor communication, record keeping and failures in properly considering earlier medical notes before meetings, and risk assessments being carried out;
  • There was a failure to update key documents concerning care planning, safety planning and risk assessments;
  • There was a lack of continuity of care in that Mark rarely saw the same practitioner twice during his involvement with the Crisis Team, and that this is not unusual due to how the Crisis Team works;
  • That on the 16 April 2022 Mark’s daily visits were reduced so that he didn’t receive a visit on the day of his death, despite his risk having been assessed by an experienced Clinical Practitioner on 15 April, which required him to have daily contact;
  • A failure to properly engage Mark’s family in his risk assessments and safety plans;
  • Failure to review medication needs and make appropriate referrals at an earlier point, including to veterans specific mental health services.

Commenting after the inquest, Mark’s family, said:

“The difficulties Mark was experiencing became all too clear on 28 March 2022. However, with the events of that day came something of a palpable relief that having had fringe involvement of the mental health system, over the years, there would now be professional, coordinated, compassionate and committed support for Mark and his family.

“The reality of that support was that the organisation was too slow to respond, reluctant to be inclusive, displayed an inability to follow their own plans, uncommunicative with us as his family, lacking in resource and had staff that were short of experience making key decisions about his risk.

“The very least Mark deserved was to be afforded the same care and consideration that he showed to all those who had the fortune to know Mark.”

Mark was a genuinely lovely human being, with so much more to offer, and as many others in society deserved far more from the mental health system. A system which is failing both those in our society who are reliant on their help when in crisis but also failing their staff in giving them the necessary time, resources and skills to help those that are dependent on them.”

Mark’s family is being represented by Lily Lewis of our inquests and Inquiries team, instructed by Gemma Vine of Ison Harrison Limited.

This article is adapted from the original press release written by Gemma Vine.

This case has been widely covered in the media:

Army veteran who took own life was ‘failed’, says widow – BBC News

‘Genuinely lovely human being’ failed by the system supposed to protect him, say heartbroken family – LancsLive

Inquest held into death of military veteran Mark Rodhouse | News and Star

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