'No other place' for psychotic patient who killed

Staff on duty when a teenage mental health patient killed another patient at a Hampshire hospital had "no other option" than to admit the teenager onto their ward, despite being told he was too "high-risk", an inquest has heard.

Owen Herbert, 19, strangled Richard Laversuch as he slept, in the early hours of 27 November 2021, hours after being admitted to the recently refurbished Juniper Ward at Parklands Hospital in Basingstoke.

The coroner warned the court in Winchester this morning that evidence from ward staff at the inquest into the 63-year-old from Andover's death was "bound to be upsetting".

During the hearing, one nurse broke down in tears as she gave her testimony.

The court heard that while the "low-risk" Juniper Ward only had nine patients out of a possible 18 on the evening Herbert was admitted, it was "short-staffed", as one member of staff had not turned up and another had been moved elsewhere.

Both registered mental health nurses on duty said they raised what they considered to be "unsafe staffing levels" that night with a senior manager and were told another ward was in greater need of staff because it had higher risks.

All four staff who gave evidence agreed they were told at the start of their shift that if Herbert arrived, he had been deemed "too high risk" for Juniper Ward and should instead be admitted to the hospital's secure unit.

The nurse in charge of the ward that night, Linda Chidawanyika, told the inquest she was "surprised" when reception called at 23:10 GMT on 26 November to say Herbert had arrived, "because we were not expecting him".

After she and a colleague quickly read his notes, she said they also concluded he was "too risky for us" and told reception to call the more secure Psychiatric Intensive Care Unit (PICU) instead.

But there were "no beds available" on PICU and as Herbert's admissions paperwork stated he was to be admitted to Juniper Ward, they agreed to "accept" him and they would continue to assess his risk.

Herbert had psychosis and had left home with weapons and was hearing voices telling him to kill people the court had been told.

She said he had not presented in an "aggressive" manner: "When I went to meet him, he walked freely, normally, he was engaging, there was no immediate concern."

She admitted she did not escalate his admission to management and would only have done so "if he'd been aggressive".

Chidawanyika said when staff are at their nursing station, they had no view of the corridors or bedrooms, nor any CCTV feed of that area.

When a doctor arrived at 23:45 to assess Herbert, she confirmed the assessment was not carried out because he appeared to be asleep at the time.

She also confirmed she was one of only three staff on duty and only two when one was on their hour's break, which was the case at 03:45 when a patient - referred to as "Patient X" - came to the nursing station to tell them he had been attacked.

"Somebody had got into their room and tried to strangle them," she said, "and the person was wearing a white T shirt. The patient appeared distressed."

She said she "believed him" but after checking the other patients in their rooms "everyone was still asleep so it wasn't making sense".

Patient X then pointed to Herbert's room, so she and a support worker went into it and pulled the blanket he was covered with "off his head" and he appeared as if they had just woken him up, so she apologised and put the covers back on.

The staff went back to calm and reassure Patient X who told them he was calling the police and they would lose their jobs.

The court heard that minutes later a "very loud" scream was heard from down the corridor as if someone was saying "help" and CCTV evidence showed Herbert had entered Laversuch's room at 03:55.

When the staff went into the room they saw Herbert straddling Richard on his bed with "both of his bare hands around Richard's neck".

Support worker, Frederick Sarfo-Darkwa pressed his alarm to alert staff on neighbouring wards for help and tried to take Herbert's arm while Chidawanyika jumped onto bed to try to pull him away.

With the help of staff responding to the alarm, Herbert was moved out to the corridor where he was "aggressive".

The coroner told Chidawanyika: "We know that you couldn't save Richard, but you tried as a team?"

She replied "Yes" and then started to cry.

Later she told the court she had known Laversuch as a patient "pretty well" after nursing him for about six months and that he was quiet, kind, calm and compliant with his medication.

She said when she had asked him that night how he felt about being on the newly reopened Juniper ward he told her "he felt at peace because the previous ward was too chaotic" and when she said she had heard he had been dancing, he "just smiled".

"He said good night ladies, they were the last words I heard from Richard", she added and began crying again.

The other nurse on duty that night, Sharon Badza, had been on her break when Herbert had tried to strangle Patient X and killed Laversuch.

She agreed with Chidawanyika that their ward had "unsafe staffing levels" and because of the way Herbert presented when he arrived they had believed at that time, "in the right place" on Juniper ward.

The coroner challenged her on why they had not "escalated" his arrival to others, after being told at the beginning of the shift that he posed "too high a risk" for their ward, she conceded: "In hindsight I probably should have called the on-call manager."

But she added there was a lack of documentation on the system from other mental health and social work teams and they "felt he was in the right place and we had no option, as we had no other place to put him."

Parklands Hospital was run by Southern Health NHS Foundation Trust at the time of the killing.

It's now run by Hampshire and Isle of Wight Healthcare NHS Foundation Trust which has agreed there were communication failures before Herbert's admission.

After pleading guilty to manslaughter, Herbert was given an indefinite hospital order in 2023.

The inquest continues.