Mental health review demanded after Happisburgh man’s train suicide

Lawyers have demanded an urgent review of procedures at a Norfolk NHS mental health trust criticised by a coroner over the suicide of a Happisburgh man whose repeated requests for help in the weeks before his death were ignored.

Peter Bane, 47, died when he was hit by both a passenger and a freight train on February, 16, 2010.

He was found with a suicide note in his pocket and had told Norfolk and Waveney Mental Health NHS Foundation Trust that he was contemplating taking his own life on at least three occasions in the two weeks prior to his death.

On Thursday, the second day of an inquest heard that Mr Bane's death could have been avoided if vital information had been passed on by the county's mental health trust, said a coroner, who is asking the authority to look again at one of its practices.

His wife Angela criticised the health services for failing him and she believes he would have responded to treatment and still be alive today.

Depressed Mr Bane, jumped in front of a 75mph freight train at Witham railway station in Essex. He had told his doctor what his plan was but that specific intention was not written down by a non-medically trained receptionist at Norfolk & Waveney Mental Health NHS Foundation Trust when GP Satish Singh, of Staithe Surgery, Stalham, urgently referred Mr Bane to the crisis team.

The jury returned a verdict that father-of-three Mr Bane, a senior road safety officer with Amey Consulting in London, killed himself while the balance of his mind was disturbed.

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Essex assistant deputy coroner Eleanor McGann said after the verdict she would be writing a report to the mental health trust asking for action to prevent a similar fatality and it would have 56 days to respond.

'My concern is that the indication Dr Singh gave doesn't appear to have been relayed to the correct people within the trust. I am asking for it to be looked into.'

During the hearing Mrs McGann had said 'vital information was not conveyed' and she was concerned that untrained staff were completing forms which included risk assessment.

She said she wanted the trust to clarify what its practice was and, if necessary, to reconsider whether it was appropriate that untrained staff should carry out that task.

Mrs Bane said after the hearing: 'I feel completely let down and angry. It is obvious that more should have been done to prevent his death. Peter did exactly what he said he would do and the mental health services have failed him.'

Her husband, with whom she has a 12-year-old daughter, had battled through previous episodes of depression and she said there was no reason why treatment would not have been effective this time.

Anita Jewitt, a medical law specialist from Irwin Mitchell representing the family, said: 'Peter Bane was a hardworking, professional man who is sorely missed by his family and friends. His family have suffered enormously over the past year and wanted the inquest to provide answers to their questions over the events leading up to his death.

Aidan Thomas, the trust's chief executive, said: 'On behalf of Norfolk and Waveney Mental Health NHS Foundation Trust I would like to offer my sympathy and condolences to the Bane family for their loss. The trust would like to give assurance that the letter from the coroner will be given careful consideration.'