Bereaved parents of Chesterfield man say son was “badly let down” by mental health ward

Martin and Jennifer Conlon say their son Alasdair Conlon “did not receive the care that he deserved” while an inpatient at Chesterfield’s mental health Hartington Ward.

In a statement released after his inquest this week the bereaved parents said: “Alasdair and our family were badly let down by Derbyshire NHS foundation trust.

“He did not receive the care that he deserved and the confusion over his care plan led to leave being granted which was inappropriate for someone as vulnerable as Alasdair.

“This, together with lack of communication between the health authority and his family put Alasdair in an unsafe position.

“We are keen that - in the light of what happened to Alasdair - procedures and protocols change so that no-one else is put in this position.”

Alasdair was detained at Chesterfield Royal Hospital under the Mental Health Act in April 2017, having been diagnosed with schizophrenia, however he died three months later.

A jury inquest at Chesterfield Coroners Court heard this week how the “accomplished surfer”, musician and DJ was granted weekend leave to his flat on July 7.

However he never returned to the unit as expected on July 9, having been found dead at his Whittington Moor flat the same day by his father Martin after taking heroin.

Jurors concluded that the decision to grant weekend leave was “rushed” by Hartington Ward staff and a failure to check or review documents “contributed” to Alasdair's death.

This decision was made the same morning of Alasdair’s release at one of the regular morning meetings which were “restrictive” and “not for major decisions such as granting leave”.

Crucially, “really sweet and really caring” Alasdair’s usual doctor was off sick and a locum consultant psychiatrist was responsible for the decision to permit leave.

It emerged during hospital staff evidence that the views of Alastair’s parents – who thought he was “not safe” on his own at his flat – had not been sought prior to the decision being taken, contrary to section leave policy.

Coroner Peter Nieto told jurors the policy required that loved ones be contacted prior to authorisation - however this was not done.

Following the inquest’s conclusion Lucy McKay, of support charity “Inquest”, said “the value of the input of family members in the care of mental health patients is well known”.

However she added: “It is still forgotten or overlooked far too often.

“It is clear Alasdair’s family were strong advocates for his care - they have been badly failed by Derbyshire Healthcare NHS Foundation Trust.

“We hope the Trust will now take action on the issues exposed by this inquest and that mental health hospitals nationally will critically consider their own practices.”

Neil Cronin of Southerns Solicitors, who represent the family, said: “Four years on from Alasdair’s passing a conclusion had finally been reached regarding the circumstances.

“Overarching themes throughout have been in relation to communication, or a lack thereof and diversion from Trust policy when record keeping, risk assessing and implementing protective factors for the issue of section 17 leave.

“The merit of familial involvement continues to be firmly foregrounded as an additional layer of support for vulnerable persons.

“The family hope that the Trust will heed the findings of this inquest, namely those made in relation to determining the appropriateness of granting section 17 and seek to ensure that identified failures are mitigated within the future.”

The inquest heard Alasdair died due to mixed drug toxicity and gave a verdict of death by misadventure.

Evidence was heard that Alasdair was naive about the effects of heroin which may have been the reason he took the amount he did.

Jurors concluded he had used heroin “recreationally” or "as an attempt to self-medicate” but “not to cause himself harm”.

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