Hillingdon Hospital has admitted liability for the death of a father who committed suicide while the nurse who was supposed to be looking after him went on a break.

Rory Magill, 44, was left unattended despite being a known suicide risk, having been admitted to A&E because he tried to kill himself by swallowing antifreeze.

Hillingdon Hospitals NHS Foundation Trust, which runs the hospital in Pield Heath Road, has now accepted responsibility for a string of failings in his care, admitting that had he received the one-to-one observation he required his death could have been avoided.

The father-of-four's widow, Anita Magill, 43, of St Helen's Close, Uxbridge, is calling for lessons to be learned from the tragedy.

She said: “Rory was completely let down by those who were supposed to be keeping him safe and I am still trying to come to terms with what has happened.

“As a family we have lost a loving husband and father because of inadequate care, policies and procedures which jeopardise the safety of vulnerable people.”

Self-employed electrician Mr Magill was admitted to the hospital's A&E department on June 12, 2013.

The hospital did not have the usual drug antidote needed to treat his antifreeze poisoning, so Mrs Magill was sent out to buy alcohol – an alternative treatment. Mr Magill was prescribed 500ml of vodka and one strong beer per hour, despite being known to have had alcohol problems.

Shortly afterwards, Mr Magill was assessed by a psychiatric liaison nurse, who deemed him to be at a medium-to-high risk of suicide and self-harm, and recommended he receive one-to-one observation.

A registered nurse was assigned to his care, but was soon asked to observe a second patient, who was being disruptive.

At 4.40am the next day, the nurse went on her break and did not hand over Mr Magill's care to another nurse, leaving him free to wander the unit unattended.

He went to the toilet and returned with a broken bathroom call bell cord, which he showed to another nurse, who believed he was attention seeking.

Soon afterwards, Mr Magill requested a cup of coffee and asked whether there was somewhere else he could sit because he was having “lots of thoughts”. A nurse said he could sit in the day room, which he did, unattended. He later returned to his bed while the nurses went about their duties.

At approximately 5.45am, at least 15 minutes after he had last been seen, the nurses noted Mr Magill missing and searched for him.

He was found hanged in the day room and, despite resuscitation attempts, was pronounced dead at 6.40am on June 13, 2013.

Following Mr Magill's death, Mrs Magill instructed specialist medical negligence lawyers at Irwin Mitchell to investigate her husband's care. She is now suing the trust.

'Sincere condolences'

Meanwhile, the trust carried out an investigation and prepared a Serious Incident Report, which found there had been a series of failings in Mr Magill's care, including:

  • No early psychiatric assessment while in A&E
  • No oral alcohol in A&E
  • No alternative antidote for antifreeze poisoning (Fornepizole) held in the trust
  • No request for a follow-up assessment by acute psychiatry in relation to Mr Magill’s behaviour on the ward
  • Inadequate implementation of one-to-one observations according to trust policy
  • Inadequate observation of Mr Magill while one of the nurses was on her break
  • Inadequate training for registered general nurses and health care assistants in relation to patients with suicidal thought or intent
  • Inadequate documentation in relation to quantifying the level of observation needed
  • Miscommunication between staff in relation to specialising (one-to-one observation) responsibilities on shift

The trust’s report concluded that the root cause of Mr Magill’s death was suicidal ideation and intent with no one-to-one observation at the time of the event.

At an inquest held at West London Coroner’s Court on April 28, HM senior coroner Chinyere Inyama said it was his “clear view that observations at some points amounted to intermittent rather than one-to-one close observations within eye sight or touching distance” and that this was a “failure”.

This led the coroner to record the narrative conclusion: “Mr Magill took his own life, in part because the risk of him doing so was not adequately monitored.”

Mrs Magill said: “We are grateful to the coroner for conducting a thorough inquiry and hope that the trust will pay heed to the shortcomings identified in their own investigation report.

“We will continue to work with our team at Irwin Mitchell in order to get justice in Rory’s memory and to ensure that no other families go through what we have over the past two years.”

In a statement, the trust said: "The Hillingdon Hospitals NHS Foundation Trust has carried out a thorough investigation into this incident and has co-operated fully with the coroner's enquiry. The trust would again like to offer its sincere condolences to Mr Magill's family."

If you are having suicidal thoughts, visit the Samaritans website, or call 08457 90 90 90.