A widow has called for lessons to be learned after her husband took his life days after doctors discharged him from a mental health hospital, ruling he was at ‘low risk’ of suicide.
Mustafa Khan, who had a history of obsessive compulsive disorder (OCD) since childhood and depression for around a decade, had been receiving treatment at the Priory North London Hospital in Southgate following his sectioning under the Mental Health Act.
However, following a nine-day stay at the hospital, it was decided that the father-of-two, of Richmond, South-West London, could be released. Three days later, Mustafa, aged 40, was found dead in woodland at Colgate, near where his family used to live in Horsham.
Following the racehorse owner and trader’s death, his wife Vera Khan instructed medical negligence lawyers at Irwin Mitchell to support her through the inquest process.
Mrs Khan has now joined her legal team in calling for lessons to be learned.
A report by assistant coroner Bridget Dolan QC found that during Mustafa’s stay at the Priory Hospital ‘relevant risk information was neither recorded nor passed on to relevant staff, a nursing care plan to assess and manage risk was not formulated, risk assessments were inadequate and did not comply with the extant policies, discharge planning did not involve the multi- disciplinary team as it should have done, the crisis plans were inadequate and were not communicated to his family’.
The assistant coroner’s report says: “Mr Khan was discharged from the Mental Health Act section and from the Priory hospital without any private or NHS health professional being informed of this. Three days after his discharge Mr Khan, who had left to live in a hotel, took his own life by hanging himself in woodland.
“Whilst it can not said that Mr Khan would not have killed himself when he did had the above shortcomings not occurred, several opportunities were lost to ameliorate or avert the risk of him doing so.”
She concluded that the death was a suicide.
Hannah Lamb, specialist medical negligence lawyer at Irwin Mitchell’s London office representing Mrs Khan, said: “This is an incredibly tragic case and, many months after Mustafa’s death, Vera and the rest of the family remain understandably devastated by the loss of a much-loved husband, dad, brother and son.
“The family had a number of concerns about the events that unfolded in the lead up to Mustafa’s death and unfortunately the inquest has validated some of the concerns. We hope that these are now addressed as soon as possible to help improve patient care.”
A statement issued by Irwin Mitchell said: “Mustafa and Vera, 32, met in 2006. The couple had two children, aged four and two. Mustafa and his brother, Murt, formed the M Khan x2 partnership and owned a number of racehorses.
“During an inquest at West Sussex Coroner’s Court, the coroner was told that Mustafa’s OCD got worse and he had started to develop sensitivity to cold and had cut certain foods out of his diet.
“In 2014, when the couple were living in Horsham, Mustafa’s mental health deteriorated and he became more isolated.
“Following medical assessment, Mustafa started taken medication for his illness in 2015. However, in around May 2017, he decided to suddenly stopped taking his medication as he was feeling much better, the court was told.
“Towards the end of October and early November 2017, he started expressing suicidal thoughts. He briefly resumed taking medication in January 2018 but stopped again as he believed that it was making his condition worse and his condition was physical, not mental. Throughout early 2018 Mustafa’s condition deteriorated and he threatened to take his own life.
“He was sectioned under Section 2 of the Mental Health Act on 6 February following another suicide threat. After six days at an NHS hospital he was transferred on 12 February to The Priory, still under The Mental Health Act. During his stay at The Priory he refused to take medication and refused to engage in any therapy programme for his OCD and with staff regarding his illness. Mustafa wanted to be discharged home to be with his family and staff assessed whether they could agree to his request.
“A report detailing an investigation into the care and treatment Mustafa received at the Priory, written by the Priory Group, identified a number of failings in his treatment. The hearing was told that a number of actions have been initiated in response to the tragic incident. They focus on improved communications and co-ordination between referring or treating agencies, more thorough risk assessments, enhanced discharge meetings and post discharge care and appropriate training for all staff to ensure lessons from incidents are captured.
“The hearing was told that Mustafa, who wanted to leave the hospital and who staff deemed to be at ‘low risk’ of suicide, was discharged on 21 February to stay at his parents’ house. A ‘keeping safe’ care plan, including a phone number which a patient could call for to speak to a mental health specialist in case of emergencies, was not completed. The family were not provided with a contact if there was an emergency and there was no follow up plan in place by the Priory.
“After staying one night at his parents’ house he checked into a hotel. On 24 February, his family could not contact him so called the police. His body was found shortly afterwards.”
After the hearing Mrs Khan said: “I was very confused why Mustafa was allowed to be discharged when it appeared he was not taking his medication and I did not think his condition was improving.
“I’m still in shock now about his death. All we wanted is for Mustafa to receive the help he needed so he could get better and come back home to his family.
“Our family can’t understand how Mustafa was discharged from The Priory and wasn’t considered at risk of harming himself despite being suicidal for several months and having not engaged in any treatment or therapy during his time at The Priory.
“I am completely devastated by the loss of Mustafa and the children miss their daddy.
“Our only hope now is that the heartbreak our family has suffered highlights the need for those with mental health issues to receive the treatment they need.
“We hope that health trusts and hospitals continue to learn from the issues which have been highlighted at inquest to ensure other families are spared the pain we have to endure on a daily basis.”
A spokesman for the Priory Hospital said: “We extend our deepest sympathies to Mr Khan’s family. Patient safety remains our absolute priority and following the incident, the hospital has strengthened its risk assessment and discharge policies and procedures. We will now carry out a further review in light of the inquest findings and carefully consider what additional changes are needed.”
The Samaritans are available 24 hours a day, seven days a week, 365 days a year. You can call them free any time, from any phone on 116 123 or you can email them at firstname.lastname@example.org.
They say: “If you need a response immediately, it’s best to call us on the phone. This number is FREE to call. You don’t have to be suicidal to call us.”