February 25, 2015
Man classed high suicide risk kills himself after being discharged twice by hospital
A man who believed he was possessed by the devil killed himself after being discharged from hospital twice in 24 hours.
Simion Costin suffered hallucinations, and was initially assessed by staff in the emergency department at Leicester Royal Infirmary as a high suicide risk, an inquest heard. But language problems and mislaid notes meant the two psychiatrists who saw him did not get a full picture of his mental state.
Mr Costin was not admitted nor given any medicine to control his condition. Instead, he was encouraged to register with a GP and sent home. But within three days, he had killed himself.
Mr Costin, who was Romanian, was working in a car wash in Wigston. His friend, Ionut Budu, who also worked at the car wash, told the inquest Mr Costin was well-liked, but began acting oddly in the first few weeks of 2014. Then in March, the situation got worse.
“He thought he was the devil and people he came into contact with were going to die,” said Mr Budu, speaking through an interpreter. “He also said there was something inside him, an insect or something. “He also said he wanted to kill himself.”
Mr Budu and workmates were so alarmed they took him to Glenfield Hospital, and later to Leicester Royal Infirmary (LRI). An initial assessment carried out by emergency department staff, with the help of a Romanian doctor, said Mr Costin was a high suicide risk. The inquest heard that Mr Costin had made an attempt on his life by jumping out a second floor window in Romania nine years earlier. His case was handed over to the Leicestershire Partnership Trust for a full mental health assessment, but there was no Romanian interpreter available. Five hours later, Dr Rafizul Islam carried out a two-hour assessment with the help of Mr Budu, and a security guard who spoke Italian. Mr Budu said Mr Costin could speak a little Italian having worked in Italy. But Dr Islam, who did not see the initial assessment, assessed that Mr Costin was not a risk to himself, and discharged him with a leaflet about registering with a GP.
The following afternoon Mr Costin had to be restrained by workmates after he started screaming. Police and ambulance were called and he was taken to the emergency department at LRI. It was not until 10.15pm, after a interpreter had been contacted, that he was seen by trainee psychiatrist Dr Christina Evans. However, Dr Evans had no notes to refer to as they had been “mislaid”. She assessed Mr Costin as suffering from a depressive condition. He had told her that he was returning to Romania in the next couple of days to be with his wife and daughter whom he missed deeply. She told the hearing: “I felt that going back to Romania was a better option than admission or medication.” But she admitted she had made her decision on insufficient information.
Mr Budu said Mr Costin had no travel plans arranged. He added that Mr Costin’s were so worried he would kill himself they hid all the knives in their shared house, and wanted him to be admitted to hospital. “They did not admit him,” he said. “They also did not give him anything to calm him down.”
Three days later, on March 25, Mr Budu found Mr Costin on his bedroom floor. He had cut his throat, and could not be revived. Coroner Catherine Mason asked Mr Budu: “Do you think the hospital failed to take your friend’s condition seriously?” He replied: “Yes I do.” Mrs Mason said it was clear Mr Costin was unwell. She praised his friends for doing all they could to keep him safe. In conclusion, Mrs Mason said: “Mr Costin took his own life while his mind was in a state of imbalance.”
Dr Mohammed Al-Uzri, clinical director of adult mental health and learning disability services at Leicestershire Partnership NHS Trust (LPT), told the hearing that an investigation had taken place following Mr Costin’s death. He said standardised assessment documents had been rolled out across the trust to avoid confusion in the future. Assessment notes were now logged digitally so they would not be “mislaid” in the future, he said. Procedures now emphasised the need to speak to friends and relatives to obtain background information, said Dr Al-Uzri. He told the hearing that the trust’s policy was to employ professional interpreters.
Coroner Catherine Mason said she was pleased the LPT had made changes after Mr Costin’s death.
In a statement after the inquest, Dr Al-Uzri said: “We are deeply saddened by the death of Mr Costin and our sympathy goes to his family.
“Following his death, we carried out a detailed review of Mr Costin’s care.
“Our investigation identified ways we could improve the way relevant information about the patient is taken, recorded and acted on in the future – and we welcome the coroner’s comments that she is pleased to see the changes that have been introduced.
He added: “The Trust is also extending its nurse-led assessment and triage service at LRI to provide 24-hour cover.”
Mrs Mason said she would write to NHS England for them to consider rolling out a standardised assessment document.
She is also going to contact University Hospitals of Leicester NHS Trust to urge it to adhere to a policy of employing professional interpreters and not rely on staff members filling in.
A spokesperson for Leicester’s hospitals said: “Our thoughts are with Mr Costin’s family and friends for their sudden and tragic loss.
“We absolutely recognise the importance of an accessible and prompt translation service and would like to assure visitors to Leicester’s Hospitals that we take this very seriously. Upon receiving the coroner’s letter we will address the concerns raised as a matter of urgency.”