The ‘utterly avoidable’ death of a man in a mental hospital happened due to staff failures, a jury has found.
Richard Laversuch, 63, from Andover, died at Parklands Mental Hospital in Basingstoke on November 27, 2021, after being strangled by another patient, Owen Herbert, then 18.
An inquest with a jury ran between Monday, July 13 and Wednesday, July 29 at Winchester’s Coroner’s Court.
The jury said Mr Laversuch was ‘unlawfully killed’ after failures by staff led to Mr Herbert being admitted to an inappropriate and less secure ward.
Addressing the jury, Coroner Mr Nicholas Walker said: “By your conclusion and the admission made by the Trust, the death of Richard, it seems, was utterly avoidable; it shouldn’t have happened.
“I can’t imagine how hard it is for Richard's siblings to learn how easily that death could have been avoided.”
In November 2021, Mr Laversuch, who had schizophrenia, was staying in the Juniper Ward for acute admissions and was awaiting a placement to be discharged.
Mr Herbert, from Overton, was admitted just after 11pm on November 26 after a Mental Health Act investigation deemed that he should be detained for his own safety.
Prior to this, Mr Herbert had been hearing voices, citing that ‘life is a game’ and that he needed to obey the voices’ orders; otherwise, he would be ‘tortured’ and ‘erased.’
He had been seen leaving the house with knives, a cricket bat, and weapons on several separate occasions and had exposed himself in public.
When he arrived at Parklands, a bed on the Hazel Ward, the Psychiatric Intensive Care Unit (PICU) was not available, so he was admitted to the Juniper Ward.
An approved mental health professional (AMHP) from Hampshire County Council had named the Juniper Ward, which was a ‘key factor’ and ‘introduced confusion into the admission process’, the jury said.
In their record of inquest, the jury said: “It is not the AMHP’s role to recommend a clinical setting. The AMHP failed in their setting to act as an effective coordinator.
“The actions of the AMHP more than minimally contributed to the death of Richard Laversuch.”
The Hampshire and Isle of Wight Foundation Trust has admitted the patient should have been admitted to PICU and that there was a failure to follow national standards.
The trust has also admitted the Juniper Ward was ‘insufficiently staffed’ during the night shift.
Upon Mr Herbert’s arrival to the ward, staff carried out a risk assessment based on a ‘brief observation’ and ‘placed an over-reliance on the calm presentation of the patient,’ the jury found.
The jury said: “The risk assessment undertaken on the ward was strongly influenced by brief observation of the patient due to staffing constraints.”
The jury said there were ‘missed opportunities to revisit concerns’ and ‘there was no barrier to escalation, but the opportunity was missed.’
At Juniper Ward, Mr Herbert was seen walking in and out of his room and heard evidence that he attempted to strangle another patient at around 3.40am on November 27.
The patient complained to a nurse, who checked on Mr Herbert and believed him to be ‘in a deep sleep.’
The jury said that the nursing staff ‘doubted’ the attack due to lack of evidence and the ‘remaining clinical staff did not consider the seriousness of the risk to other patients.’
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At 3.55 am he was seen entering Mr Laversuch’s room and was found by staff to be strangling him.
A post-mortem examination concluded that Mr Laversuch died of manual strangulation.
As previously reported, a statement from consultant forensic psychologist, Dr Oliver White, stated that Mr Herbert said the voices had instructed him to kill someone immediately before strangling Mr Laversuch.
Mr Walker said he will issue a prevention of future death as he is concerned about the lack of clear guidance for admissions of patients into wards.
He said: “It’s not five years on, I’m satisfied the trust does intend to put things right, but those good intentions need to resolve quickly.”
He thanked the jury for working ‘incredibly hard’ and performing their public service to ‘the highest standard.’
In his closing statement, Mr Walker said: “I must pay respects to Richard’s family. Your sharp intelligence, obvious warmth and generosity are clear.”
In a trial in February 2023, Mr Herbert pleaded guilty to manslaughter by diminished responsibility, assault occasioning actual bodily harm and assault by beating of an emergency worker.
He was sentenced to an indefinite hospital order and will only be released when a mental health tribunal considers him to be safe and the Secretary of State consents.
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