A NURSING boss has criticised the care of a 58-year-old who leapt to his death at the John Radcliffe Hospital in Oxford.

David Brooks, who was under 24-hour watch, escaped the attention of his assigned mental health nurse at about 1.45pm on January 15.

He ran out of the neurosciences ward to a stairwell on the second level, where he jumped to his death.

Mr Brooks, from Moreton-in-Marsh, Gloucestershire, had been transferredfrom the Warneford Hospital in Headington, where he had been detained since October 2013, to the JR the day before.

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He had suffered from depression since his teens and was due to be at the JR for three days of tests, Oxfordshire Coroner’s Court heard on Thursday.

The head of nursing for adult mental health services at the Oxford Health Foundation Trust, Susan Haynes, told the court: “There was inadequate sharing of information between the [two hospital] teams.”

Mrs Haynes said a joint review of Mr Brooks’s death by the OHF Trust, which looks after mental health, and the Oxford University Hospital NHS Trust, which administers the JR, had found “some notable lapses in care”.

The transfer process between hospitals was “not safe” and “does not guarantee continuity of care”, she said.

Mr Brooks, a widowed accountant, was on “level three” observation, which meant he had to be accompanied by a mental health nurse at all times and stay within the nurse’s eyesight, the court heard.

The joint review has recommended that in future a single psychiatric team should manage a mental health patient who is transferred between hospitals.

Mr Brooks’s son, Matthew Brooks, 32, a hotel assistant manager from Bournemouth, told the Oxford Mail outside the court: “I’m devastated at the loss of my father. I hope the circumstances in which he died will bring to light flaws in the NHS that can be ironed out. I hope his death is not in vain.”

Mr Brooks praised the work of nursing staff, saying they had done “a marvellous job” of looking after his father over the years. But he criticised management. “If there any issues at all it sits at the corporate level,” he said.

The court heard that the day before Mr Brooks’s death a nurse, who had accompanied him to the JR, had logged in the Warneford’s reporting system that he was “at high risk of absconding and feeling suicidal”.

But the next day Crispen Mayo, the fourth Warneford nurse to watch over Mr Brooks at the JR, did not check any of the notes before he started his shift at 1pm, the court was told.

A coroner’s court jury, which is required for the death of a detained person, delivered a narrative conclusion: “After voluntarily leaving his ward on Level Two, West Wing, at approximately 13.44 hours, he scaled the stairwell barrier and released himself, falling several storeys. He received multiple significant injuries upon impact with the ground. No other person was involved. He was pronounced dead at 13.50 hours. There may have been defects in communication and supervision. It is not possible to determine whether these contributed to his suicide.”

Oxford University Hospitals NHS Trust medical director Dr Tony Berendt said: “Our thoughts and deepest sympathies go to the family of Mr Brooks over his tragic death.

“Oxford University Hospitals and Oxford Health have both had time to reflect on the events that led up to his death and to learn lessons.”

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