A HOSPITAL has been criticised for failings in the mental- health system that contributed to the tragic death of a Halifax man.
Christopher Blagbrough, 22, of Central Park, Halifax, hanged himself while a patient in Castle Hill Unit at St Luke's Hospital, Huddersfield.
His parents Peter and Jeanette have had to wait for three years for a jury inquest into his death and are in contact with Halifax MP Alice Mahon to try to stop another tragedy in secure health units.
West Yorkshire Coroner Roger Whittaker said it had been an emotive case.
"The family had grave concerns about the way Chris-topher had been treated while in Castle Hill Unit,'' he said.
"The jury were directed they could bring in a narrative finding rather than the short form conclusions generally used following recent decisions in the House of Lords and the High Court.
"The jury concluded Christopher took his own life while the balance of his mind was disturbed. They also expressed the view that Christopher's death could have been prevented.''
Health bosses have now apologised for the failings and distress caused to Mr and Mrs Blagbrough.
Christopher's parents believe he was driven to suicide after being made to endure a living nightmare in the unit.
He was moved to St Luke's from Doncaster Prison after a stabbing incident but his father was so concerned about his treatment in the unit he absconded with his son to Spain.
As a result Mr Blagbrough was banned from seeing Christopher, who had attempted suicide nine times.
A series of tragic events culminated in his death and an investigative panel also ruled the system had failed him.
"The standard of care for Christopher Blagbrough on the night of his death was inadequate and fell beneath the standard of care that should have been reasonably provided,'' ruled a panel of eminent health professionals. The inquiry found:
He ought to have been placed in a medium-secure unit for a comprehensive risk assessment.
Overall risk assessment and management of it was inadequate.
Staff made unwarranted assumptions about the well- being of Christopher and failed to ensure his safety
The observation policy was inadequately implemented
Staff panicked after discovering Christopher's suicide.
He was left hanging.
He was certified dead at 6.10am but his family was not informed for more than four hours. South West Yorkshire Mental Health NHS Trust spokeswoman Bronwen Gill confirmed three nursing staff were later disciplined and sacked for not following procedures on the night he died.
Calderdale and Huddersfield NHS Trust and South West Yorkshire Mental Health NHS Trust have now apologised for failings and issued a joint statement.
Judith Young, Chief Executive of the mental health trust, which was set up in April 2002 to manage mental-health services, said: "On behalf of the NHS we offer our sincere sympathies to the family of the patient who tragically died and apologise unreservedly for the failings that have been identified.
"This incident has been thoroughly investigated, both internally and externally.
"Sadly, we cannot change the tragic events that happened but we can learn from them and we have made many changes following this incident.
"Much progress has been made in our service during the past three years. All the actions recommended by an external inquiry have been implemented and improvements made to the physical environment of the unit.
"We have a comprehensive training process in place for all staff to promote understanding of all policies, procedures and working practices, as well as a structured training programme to support staff as they undertake their duties."