The inquest into the death of a depressed man has heard how he went missing from the Royal Derby Hospital - after being allowed to go outside for a cigarette.
Derbyshire’s senior coroner Dr Robert Hunter said Ricky Hill may not have been let out if he had undergone an earlier risk assessment and had a care plan.
Dr Hunter also issued a stark warning following an incident outside Derby coroners’ court which happened as the inquest took a ten-minute break on Monday afternoon.
Mr Hill, of Somercotes, was admitted to the Royal on the evening of September 22, 2014, after he took an overdose of painkillers.
The 30-year-old went missing the next day and was found hanging from a tree near Balmoral Close in the city on January 10, 2015.
He was depressed after a split from his wife of eight years and had previously tried to commit suicide, the court heard.
During the third day of the inquest, A&E staff nurse Geoman Manuel - who dealt with Mr Hill when he was first admitted - told Dr Hunter he was not aware of the SAD PERSONS scale, which helps determine a person’s suicide risk.
Dr Hunter said: “Had this been used in A&E, Mr Hill would have come up eight out of ten - high risk.
“He would have been placed on level three observation.”
Mr Manuel said the ward was busy - but Dr Hunter told the court the SAD PERSONS risk assessment would have taken ‘30 to 40 seconds’.
Mr Manuel added: “At the next stage, Mr Hill would have been assessed by my colleagues in more detail.”
Later, Mr Hill was seen by Dr Shawn Joseph, a clinical fellow at the Royal’s A&E department.
Mr Joseph said: “At that point, I didn’t think he was going to abscond - I didn’t feel he was going to do anything.
“His parents were present (in his cubicle) - but I can’t reassure the court they would have been there all the time - and I knew the mental health team was aware.
“From my clinical judgement, I believed he was very much willing to cooperate with medical professionals and work with us.
“I didn’t think he needed an urgent assessment by the mental health team.
“I was satisfied he was in a safe environment in the emergency department.
“If he’d expressed he wanted to harm himself or made any attempts to harm himself in the emergency department, this would have triggered me to instigate one-to-one nursing supervision and security.”
Dr Hunter said: “Had there been an earlier risk assessment, had there been a care plan, Mr Hill may never have been allowed to go outside for a cigarette.
“You can never fully eliminate the risks but you can take steps to reduce the risks.”
Neil Lister, a liaison nurse specialist with Derbyshire Healthcare NHS Foundation Trust based at the Royal, said Mr Hill could not immediately receive psychiatric treatment as he was under medical treatment following the overdose.
He was, however, seen by a mental health nurse the following morning.
After a ten-minute break in proceedings, Dr Hunter expressed concern about an incident which happened outside the court.
He said: “I don’t know exactly what happened but that behaviour and language is completely unacceptable.
“If there’s any repetition I will hold those responsible in contempt of court and they could be fined or imprisoned.
“It won’t be the first time I’ve sent someone to jail,” he warned.
At the start of the inquest last Thursday, Mr Hill’s wife Dawn Hill, of Welbeck Close, Somercotes, said the couple separated just seven weeks before he was admitted to the Royal after taking the overdose.
She said following their temporary split he started taking drugs and drinking heavily as he was depressed.
Mrs Hill described her late husband as ‘a very loving and caring family man’.
The inquest - which is expected to last a total of seven days - continues.