Gary Mavin: Hospital suicide patient 'feared being sent home'

A mental health patient killed himself because he feared being discharged from hospital, an inquest has heard.

Gary Mavin died at the Priory Hospital in Arnold, Nottinghamshire, on 20 September 2020.

Nottingham Coroner's Court heard the 54-year-old's release was halted once his fears became apparent, but he was not told about the change of plans.

A psychiatrist said failing to inform Mr Mavin was a regret that would stay with him for the rest of his life.

The father-of-three, from Hucknall, checked into the mental health unit on 31 August after being treated at Nottingham's Queen's Medical Centre (QMC) for an overdose he had taken at home.

A week later, consultant psychiatrist Dr Daniel Moldavsky assessed Mr Mavin, and told him about plans to potentially discharge him.

At the time, the patient was afraid of being sent home because he believed his neighbours wanted to kill him, the hearing was told.

On being told this, Dr Moldavsky said he stopped plans to release him.

"It is perhaps something we should have mentioned to him," he said.

"I regret that I didn't tell Gary. Why I did not is a question that will stay with me for the rest of my life."

The inquest heard that during his time at the Priory Hospital, Mr Mavin was found with a ligature and also told staff he was hearing voices.

Assistant coroner Laurinda Bower asked why this was not "taken seriously" by the doctor.

"Had I have thought he was suffering a psychotic disorder I would probably have reacted in a different way," said Dr Moldavsky.

"On reflection I could have taken a different approach.

"Any time I can't help a patient it stays with me for the rest of my life."

He said he did not believe Mr Mavin was a risk to himself while in hospital, but agreed further risk assessments should have been carried out.

Another member of staff told the hearing Mr Mavin was under observation, so would be checked on four times an hour.

But on the evening of 20 September, healthcare assistant Edmore Zindove saw he was missing from his bedroom.

"I knocked on the door and there was no answer," he said.

"I checked on the other patients and when I got back to the lounge I asked a colleague if he had seen Gary.

"That's when we went back to the bedroom and went into the bathroom and found him."

Ms Bower suggested the patient could have hanged himself in the en-suite bathroom while the nurse continued checking on other patients.

The family's lawyer, Rachel Young, asked Mr Zindove why he did not immediately inform the nurse in charge when he noticed Mr Mavin was not in his room.

He replied: "I should have done that. I apologise.

"I was panicking, running around. I was overwhelmed by the situation."

Mr Mavin's wife previously told the inquest he had written worrying text messages and posts online days before his death.

His sister, Shona Bradley, said this made it clear there were "serious concerns" for his mental health.

The inquest also heard from a nurse at the QMC, who said an assessment of Mr Mavin was not carried out before he was admitted to the Priory, and therefore relevant information about his mental state had not been passed on.

Nottinghamshire Healthcare said it was carrying out an internal investigation following the death.

Ms Bower adjourned the inquest to await its conclusion and also to obtain an expert opinion from an independent consultant psychiatrist.

The inquest resumes in November.

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