Inquest hears of miscommunication that stopped search for missing James Rugg

It emerged that James Rugg hadn’t come home when his partner called the Oxfordshire force the following day to ask what progress had been made in the search for the missing 51-year-old.

The dad-of-two, who was admitted to the Horton Hospital on May 5, 2020, after suffering seizures while at alcohol rehabilitation facility Banbury Lodge, was found dead in farmland five days after he went missing from ‘F’ ward.

The night before he absconded, an on-call doctor recorded on his electronic patient record - which staff on ‘F’ ward had only started using when the unit was converted from an orthopaedic trauma ward at the start of the pandemic - that Mr Rugg should be given 1-1 care.

Nurses denied that the doctor told them the patient should receive 1-1 care ‘if possible’, although they independently placed him on ‘bay watch’ as they were concerned about him wandering around the ward. The note about 1-1 care on his electronic patient record was not seen by the night nurse and he was not given 1-1 supervision after the morning shift started at 7am on May 7.

Mr Rugg’s s partner, Stephanie Mitchell, said she received a call from him at 9.45am from the hospital. “He was very distressed and didn’t know where he was and wanted me to come and get him.”

Ward clerk Katie Bazely said in a statement she’d called 999 at around 11.30am to report Mr Rugg missing. “The operator asked me if Mr Rugg had capacity to leave and I said yes (because this was my understanding from what the nurse had told me). My recollection is that the operator said that if he had capacity then he could make the choice to leave but he would check with [his] supervisor.”

She passed the phone to deputy sister Mae Vergara, as she was ‘concerned’ about the 999 call handler’s response. Ms Vergara said in a statement: “I again expressed my concern and wish for them to look for him and make sure that he is safe or return to the ward.”

The inquest heard that neither Thames Valley Police nor West Midlands Police had a record of the call, having checked 999 logs around the time the call was supposedly made.

A second emergency call was made at around 2pm by doctors.

An investigation was launched and a number of press appeals issued. Officers were tasked with checking CCTV and looking at whether Mr Rugg could have tried to board a train or hitch a lift back to Coventry.

File image of Horton Hospital, Banbury

In the early hours of May 8, Thames Valley Police was emailed by West Midlands Police telling them - wrongly - that he had returned home. That inaccuracy - blamed on a miscommunication between West Midlands Ambulance Service and West Midlands Police - was discovered later that morning, when Mr Rugg’s partner Ms Mitchell called the Oxfordshire force to check on what progress had been made.

On May 12, officers in a National Police Air Service helicopter found Mr Rugg’s body in a ditch in farmland east of Banbury and around two miles from the hospital. A post-mortem found he died of hypothermia and alcoholic ketoacidosis.

An inquest this week heard that the helicopter was launched on the afternoon of May 12 after a member of the public called police earlier that day to report that he’d spoken to Mr Rugg five days earlier.

Supt Emma Garside, now the Thames Valley Police commander for the area, said she’d been told that a request had been made for an aerial search earlier but the request was refused as at the time officers were unable to narrow down the area that should be searched.

After recording a narrative conclusion, senior coroner Darren Salter said he would be writing a letter to the National Police Air Service via Thames Valley Police flagging the issue of the helicopter resource. He did, however, recognise the air support was a ‘scarce resource’ in ‘great demand’ but said a letter may prove ‘helpful, looking to the future’.

The inquest was told that a number of changes had been made by both Oxford University Hospitals NHS Foundation Trust, which had improved training on electronic record keeping, and Thames Valley Police.

Despite no lessons being flagged in an Independent Office for Police Conduct report, Supt Garside said a number of improvements had been made. They had improved communications with the ambulance service, learning from the miscommunication between West Midlands ambulance service and police that led to Banbury police mistakenly being told that Mr Rugg had returned home.

The coroner said an opportunity was missed on the morning of May 7 to assess whether Mr Rugg had capacity to discharge himself from hospital. “If there had been 1-1 or closer supervision that in itself would inform a decision about whether a capacity assessment was required but also with closure 1-1 supervision and also likely to have prevented the opportunity to desist or likely stop James from leaving the hospital.”

Both the coroner and a number of witnesses noted that the incident had happened during the first wave of the coronavirus pandemic, when hospital staff were getting used to different ways of working.

File image of Mr Rugg Picture: THAMES VALLEY POLICE

Mr Salter concluded that a 999 call was made by ward staff after Mr Rugg was found to have left the hospital at around 11am on May 7. However, he said he was ‘less sure’ what was said by the operator and noted that no record of the call had been found by either West Midlands or Thames Valley police forces.

He said: “I don’t have any evidence that this quite short delay if that is what it was in terms of getting a missing persons investigation off the ground is likely to have altered the outcome.”

Mr Rugg, a former senior programme manager, was described by his partner Ms Mitchell as a highly intelligent Cambridge graduate who spoke several languages, was ‘very fit’ and had climbed Mt Snowdon in North Wales in just two-and-a-half hours with his two boys in the year before his death. His alcohol consumption had increased after losing his job and, after speaking to his family, he had checked himself in to Banbury Lodge rehabilitation facility.