Nurses at a psychiatric hospital failed to carry out a full search for a missing mental health patient later found drowned in a bath on a neighbouring ward, an inquest has been told.
The family of Morgen Zawodne, who worked as an IT expert for the New York Stock Exchange, told Bradford Coroner Roger Whittaker how they pleaded with nurses at Bradford’s Lynfield Mount to listen to their fears that he “had gone downhill” since arriving on Maplebeck ward a few days before.
The graduate, 39, of Green Close, Fairweather Green, had been admitted as a voluntary patient after trying twice to take his own life.
His sister Sarah Zawodne told the inquest: “We pleaded with the nurses every night. We told them he’s not right and asked what are you doing. No-one at any point did anything to appease us or give us any confidence in Lynfield Mount.”
Mr Zawodne was discovered missing at 9.30am on October 27 last year, a search was carried out in the hospital but the inquest heard the member of staff who checked the other ward accessible via a courtyard had only gone to the hallway and communal area.
Rooms and locked areas had not been searched breaking search procedures.
It transpired staff on the ward where Mr Zawodne was found had not been told there was a missing patient.
It was only when a health worker on that ward carried out a head-count that he realised a man he had seen twice in a bathroom should not have been there.
The inquest heard a cleaner had flagged up to the worker that someone, possibly the same man, had spent a long time in the bathroom she wanted to clean.
Agency worker Lloyd Jagada said when ‘it clicked’ about the extra man, he went to the bathroom and had to use his keys to force open the now locked door.
It was then he saw Mr Zawodne upside down in the bath, he activated his alarm, called for help and pulled him out. Help came but Mr Zawodne could not be revived.
He was discovered two hours after it was noticed he was missing and one and a half hours after police had been alerted in case he had got out of the hospital.
Mr Zawodne’s psychiatrist Dr Ranga Rattehalli has classed his patient as being at ‘significant risk’ of suicide but only had the choice of either having him checked every hour or being under constant observation.
He remarked that the health trust in Leeds would have enabled him to chose from five minute intervals up to one hour checks but “that was lacking in Bradford”.
The inquest heard an investigation had been carried out by Bradford District Care Trust and an action plan implemented but it was revealed that Mr Zawodne’s family had only received an abridged version of the report despite being promised the full one.
Mr Whittaker said there was “an awful lot missing” from the family’s version and he adjourned the inquest so the family could be sent the entire report and meet Trust officials.
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