Crawley man’s death: Coroner calls for improvements over discharge of mental patients from hospital

A coroner has called for better arrangements over the discharge of mental patients from hospital.

Thursday, 25th March 2021, 5:19 pm

The move comes following an inquest into the death of a Crawley man who was discharged from Langley Green Hospital without his parents knowing.

James Herbertson, who had had mental health problems for many years, died after he was hit by a train at Crawley Station in April, 2019.

And at the inquest senior West Sussex coroner Penelope Schofield, in a narrative verdict, said Mr Herbertson took his own life while the balance of his mind was disturbed.


She added: “In the days leading up to his death there was a failure to recognise and act upon the clear signs of his mental health relapse and provide him with the additional support he needed.”

Ms Schofield has issued Regulation 28 reports to prevent future deaths to both the Sussex Partnership NHS Foundation Trust and Horsham District Council.

The inquest heard that Mr Herbertson was first sectioned in 1998 but then absconded before returning and being diagnosed with schizophrenia, with possible effects of substance misuse and depression.

He lived in France for many years but returned in 2018 and was detained in Langley Green Hospital. In August of that year he was discharged to the care of the Community Mental Health Team.

His family felt he was not fit to be discharged and after sleeping rough was accommodated at the Grange Hotel which, according to the coroner, was unsuitable for someone with his problems.

He was allocated a Lead Practitioner to support him but in April, 2019, he said he wanted to go back to France but he was not thought well enough.

His situation was discussed at a multi-disciplinary meeting on April 9, when it was agreed that he should be monitored more closely but no referral was made to the crisis team.

That day Mr Herbertson sent his Lead Practitioner a text message asking her to contact him but she did not see it that evening or the following day, by which time he had died.

In her report to the NHS Trust the coroner raised several concerns, including the fact that neither his Lead Practitioner nor his parents were told about his discharge, and that the Grange Hotel was “not a safe and therapeutic environment for a person who had recognised mental health difficulties with a history of alcohol and substance misuse”.

She also said there was a failure to recognise that Mr Herbertson’s condiition was deteriorating and a lack of understanding by individual staff of what steps to take when someone was placed in “Red Zone”, as he was the day before he died.

Both authorities have been given until May 21 to respond to the coroner’s comments. Horsham District Council was issued with the Regulation 28 report because of the housing issues involved.

Anyone disturbed by this report can contact The Samaritans for free on 116 123, email them at [email protected], or visit