Jury says signs were missed in death of Saxmundham man

On Wednesday, the inquest into the death of Paul Templeton reached its conclusion. Mr Templeton, from Saxmundham, died on April 20 last year following an incident which happened while he was staying in the Woodlands mental health unit in Ipswich.

The Woodlands is located in the grounds of Ipswich Hospital in Heath Road but is a separate entity to the main hospital and is run by the Norfolk and Suffolk NHS Foundation Trust (NSFT).

NSFT had said it has made improvements since Mr Templeton’s death.

Mr Templeton had been struggling with his mental health from early 2022, which culminated in him being hospitalised with a kidney injury in December which he sustained through not eating or drinking. On January 18, 2023, Mr Templeton was transferred to the Willows ward at the Woodlands.

During the course of the inquest, staff members from the Woodlands gave evidence that Mr Templeton had gradually become better at eating, drinking and taking his medication, but that this was not consistent.

Staff believed that Mr Templeton was “on the recovery trajectory”. Indeed, staff nurse Adeshola Ayoolah observed that on the morning of April 14, Mr Templeton ate two breakfasts, which she was impressed by.

Nurse Ayoolah is believed to be the last person to have seen Mr Templeton alive. Later that morning, he took his own life, using means he found inside his bedroom.

A notebook which is believed to have belonged to Mr Templeton was recovered after his death. In it, the writer described fears their digestive system had “shut down”, and the belief that food and medication were not being absorbed by their body.

Mr Templeton had been staying at the Woodlands from January until the incident which caused his death in April. Image: Google Maps (Image: Google Maps)

The jury concluded that Mr Templeton died by suicide.

However, they said that initial and subsequent assessments of Mr Templeton had “seriously failed to recognise” that his “prolonged choice” not to eat or drink was an indication of his intention to end his life, and he should therefore have been considered a suicide risk.

Mr Templeton’s brother, Stephen Templeton, joined the proceedings remotely from America. He said that he was pleased the jury had raised this issue, as he felt that his brother had been trying to starve himself “whether consciously or unconsciously”.

The presiding coroner Mr Peter Taheri said that he would consider the jury’s findings. He asked NSFT to write to advise him of the learning NSFT has undertaken in light of Mr Templeton’s death, and said he will decide whether it is necessary to write a Prevention of Future Deaths Report in due course.

Cath Byford is the Deputy Chief Executive and Chief People Officer at Norfolk and Suffolk NHS Foundation Trust.

She said: “Our thoughts are with Paul’s family at this difficult time. We would like to pass our condolences to them and assure them that we have taken action to improve following his sad death.

“This includes increasing the records we keep about the way our patients are presenting and trialling a ‘transition group’, which will offer extra support to patients for six weeks following their discharge from an inpatient ward back into the community. This will help ensure our staff can more effectively support and monitor our service users so that they can take prompt action if the individual needs further support or intervention.

“We would encourage Paul’s family to get in touch if they have any further questions or we can support them in any other way.”

If you need urgent mental health support call NHS 111 and select option 2 or the Samaritans on 116 123. Both services are available 24 hours 7 days a week.