Inquest finds that devoted dad committed suicide whilst his mind was disturbed
The family of a man who killed himself shortly after being released from a mental health hospital paid tribute to him as his inquest concluded.
Andrew Fleming, of Annan Road, Billingham, was described as a “wonderful husband and a devoted father” by his loving wife, Gillian.
Mr Fleming, 54, died from multiple self-inflicted stab wounds at his home on May 29, last year.
The hearing heard he had arrived home on overnight release from Roseberry Park hospital, in Middlesbrough just minutes earlier.
Today, on what would have been his 56th birthday, a jury of 11 people found that he “committed suicide whilst the balance of his mind was disturbed”.
A four-day inquest, led by acting senior coroner Clare Bailey at Teesside Magistrates’ Court, found a number of issues with the care received by Mr Fleming and the communication from hospital staff to his family.
The inquest previously heard that both Mr and Mrs Fleming had doubts over whether or not he should be released home on May 29.
Mr Fleming, who spent 14 years working as a promotions manager for the Hartlepool Mail, had made several attempts to end his life in the days leading up to his release.
Just one week before, he had walked out into traffic and attempted to take a drug overdose. He had also attempted to electrocute himself the day before being released, and bought over-the-counter painkillers, with a view to taking them, on the morning he was going home.
However, doctors responsible for him told the hearing that Mr Fleming had admitted that those incidents were “cries for help” rather than actual attempts to take his own life.
The inquest heard that registered mental health nurse Rajman Serwan, who was involved in Mr Fleming’s care, had been unsure about him going home on May 29.
However, consultant psychiatrist Dr Jude Archibald, of the Tees, Esk and Wear Valley NHS Trust, said that his patient had wanted to go home, and that the first time he heard of Mr Serwan’s objections was at the hearing.
He also said that overnight leave was an important part of the care process, in order to ensure patients do not become dependant on hospital.
The jury said they accepted the pathologist’s cause of death of “stab wounds to the chest and neck”.
They gave a narrative finding, stating: “Andrew George Fleming committed suicide whilst the balance of his mind was disturbed”, with the following contributing factors;
“1. There was insufficient level of communication from the ward staff to Mrs Fleming, ie significant incidents.
“2. There was conflicting evidence as to whether there was an agreement in place between interested parties as to Andy’s care.
“3. Mr Fleming himself was unsure he should have leave.
“4. There was an over emphasis on leave and discharge from Roseberry Park.
“5. It was inappropriate for Andy to have leave on May 29, 2015.
“6. Not all relevant staff were aware of the incidents on May 28, 2015 and May 29, 2015.
“7. On the balance of probability, Andy’s demeanour would have shown as relaxed on May 29, 2015 for his home leave.
“8. There was insufficient concerns made aware to inpatient staff and inadequate communication on May 29, 2015 from Mrs Fleming to Raj Serwan.”
Mr Fleming was well-known in his home town and was also a presenter on Radio Hartlepool.
He had been the primary carer for his wife, and cited his son David, 20, as the ‘biggest achievement of his life’.
Mr Fleming had battled mental health issues since the age of 17 and suffered from severe anxiety, depression and OCD, as well as obtrusive thoughts about harming himself and others.
Mrs Fleming said her husband was an intelligent man who had a first class honours degree in social sciences.
Speaking after the inquest, she said: “We are pleased with the finding because faults have been identified and the matter is in the hands of our legal team now.
“Andy was a wonderful husband and a devoted father.”
Son David added: “Life is never going to be the same again.”