A CORONER is writing to Whitehall to express his concerns over how a psychotic mum was allowed to discharge herself from a hospital just hours before killing her two-year-old son.
Melanie Ruddell was taken to the University Hospital of Hartlepool on August 8, 2010, and was diagnosed as having acute psychosis by A&E specialist Dr Clement Agbatar.
However, when Dr Agbatar informed Mrs Ruddell that it may be several hours before a crisis team could arrive to carry out a full mental health assessment on her, she claimed she was feeling better.
Hours later Mrs Ruddell, 40, of Castle Eden, killed her two-year-old son Christy at her brother’s home in West Rainton, near Durham City, following a nervous breakdown.
She later walked into Peterlee Police Station carrying his body.
After the inquest into Christy’s death was concluded yesterday , health chiefs admitted “lessons had been learned” .
But Mrs Ruddell’s family claim their concerns “fell on deaf ears”.
Mrs Ruddell’s brother Neil Close, speaking after a verdict of unlawful killing was recorded, said: “If we were listened to at any point maybe things would have entirely different and we wouldn’t be here now.
“He (Dr Agbatar) has proceeded to let our Melanie walk out of hospital and come back to Christy.
“That, for me, is key.”
Sunderland Coroner Derek Winter said Dr Agbatar “did not appear to full appreciate the diagnostic relevance or the risk implication of the symptoms he elicited”.
Mr Winter will now write to the Secretary of State for Health to recommend that mental health awareness training for health staff while also stressing the important role family and friends play in such cases.
Delivering his verdict at Sunderland Civic Centre, Mr Winter said: “There was a common theme that information was being gathered by a number of different agencies.
“However, those agencies, although attempting to share information, were not providing it to a common source, or were providing it later after the event.”
Mr Winter added: “The communications here at times were confused, fragmented and on occasions based upon the mistaken belief that information would be passed on or information would be sought out.”
Mrs Ruddell, formerly of Dene View, Castle Eden, pleaded guilty to manslaughter on the grounds of diminished responsibility in February 2011.
Speaking about Mrs Ruddell, Mr Close, who attended the hearing with his and Melanie’s sister, Julie Stout, added: “She is as devastated as a woman can be and she will be like that for the rest of her life.”
Mrs Ruddell continues to receive treatment at a secure facility.
North Tees and Hartlepool NHS Foundation Trust’s director of nursing, Sue Smith, said: “This tragic death has been devastating, not only for the whole family but also for our staff who, without a full understanding of what had happened before the attendance at accident and emergency, did their best to care for and support the patient.
“We have looked at the facts which surround this extremely sad event and lessons have been learned. We have learned lessons, not only in the organisation but also about communication with our partners in other parts of the health service, the local authority and the police.
“Of course nothing will bring Christy back and his loss will be felt forever by the family. We extend our sympathy to the family at what must be an extremely difficult and emotional time.”