Tragic Chesterfield Hartington Unit patient was prescribed medication before overdosing, inquest hears
A Chesterfield father was prescribed four days’ worth of medication when he was discharged from the town’s Hartington Unit - and then went on to take an overdose and die on Boxing Day, an inquest heard.
Kevin Burton - who had a history of mental health issues and drug abuse - was found dead at a Chesterfield bed and breakfast on December 26, 2015, after overdosing on his prescribed medication and illiciltly-obtained substances.
The 47-year-old was admitted to the Morton ward on the Hartington Unit in early December 2015 after an attempted drug overdose.
At the beginning of Mr Burton’s inquest on Monday, Kathleen Jones said she told Dr Simon Taylor, a consultant psychiatrist at the mental health facility, that her brother would ‘kill himself’ if he was discharged.
Dr Taylor said ‘on a clinical level, there was no reason for him to be on the ward’ - and Mr Burton was discharged from the the unit on December 22.
On Wednesday, Chesterfield coroners’ court heard evidence from Dr Sugato Sarkar, who conducted an investigation on behalf of Derbyshire Healthcare NHS Foundation Trust following Mr Burton’s death.
Dr Sarkar said it was the ‘correct decision’ to give Mr Burton four days’ worth of medication to cover the Christmas bank holiday when he was discharged from the unit.
Dr Sarkar added: “Mr Burton wasn’t suicidal at the time of discharge.”
He added it was right that he was discharged from the Hartington Unit as he was ‘clinically well’ at the point of leaving.
Coroner Peter Nieto said that Dr Sarkar’s report ‘didn’t find there was any specific or significant thing that was done wrongly or could have been done differently’.
But Dr Chris Kelly, who was instructed by the coroner to carry out an investigation into Mr Burton’s death, told the court: “In my view, it was risky to give him four days’ worth of (medication).”
Dr Kelly added: “Why was it he had to be discharged on December 22? That’s not clear.
“He wasn’t really given any transitional phase.”
‘No further enquiries’ made about whereabouts
Mr Nieto told the inquest that staff from Derbyshire Healthcare NHS Foundation Trust’s in-reach team said they attended the Applewood Accommodation bed and breakfast on Spring Bank Road on December 24 - two days after Mr Burton was discharged from the Hartington Unit - but were told he was not there.
Mr Nieto added: “The in-reach team then contacted a substance misuse worker who’d seen him the day before and they said he seemed OK.
“They then reported that back to their nurse manager and it was decided to discharge him from the in-reach team.
“There were no further enquiries made about his whereabouts.”
Mr Nieto questioned whether the in-reach team should have made further checks about where Mr Burton was.
Fiona White, an area service manager with Derbyshire Healthcare NHS Foundation Trust, said: “I think there was opportunity for further exploration about where he was.”
She insisted that changes had been made since Mr Burton’s death.
The inquest continues.
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