Gary Mavin: 'Inexplicable' care failings contributed to suicide

Neglect in the way a mentally ill man was treated contributed to his suicide, a coroner has concluded.

Gary Mavin, 54, killed himself while an inpatient at The Priory Hospital in Arnold, Nottinghamshire.

He had been afraid of going home as he thought a gang was trying to attack him, but the court heard his doctor believed he was trying to get better housing.

The coroner said it was "one of the worst examples of care".

At Mr Mavin's inquest, Nottingham's assistant coroner Laurinda Bower told how Mr Marvin was admitted to the Priory, a mental health unit, in August 2020, after a suicide attempt.

While there, he told staff he could hear voices in the bushes telling him people were coming to get him.

He said he believed he was in danger from a gang and could not return home.

Despite this, he was told his discharge was being planned and a meeting about it would take place on the 21 September.

Mr Mavin killed himself the evening before.

An undated note found in his bedroom spoke of his fears about the gang, said he was getting "no help" and added "I'm barely hanging on to my sanity".

Ms Bower said "serious and inexplicable omissions" in his care contributed to his death.

These included his condition being misdiagnosed resulting in him not being given the right treatment.

She added: "Perhaps the most concerning aspect of Gary's care was the approach adopted by his named consultant psychiatrist, Dr Moldavsky."

She said another doctor had told the court Dr Moldavsky "had formed the impression that Gary's symptoms were the product of 'malingering, manipulation or aggravation of symptoms' in order to obtain better accommodation".

She added Dr Moldavsky said that by 19 September he had changed his mind about sending him home, but admitted he did not tell Mr Mavin.

In her conclusion, Ms Bower said she was satisfied "Gary died as a result of suicide, contributed to by neglect".

She added: "Gary's case is one of the worst examples of care provided to a vulnerable, mentally ill, patient.

"At his point of need, when he was most vulnerable and frightened, the care afforded to him went from disjointed and confused, to seriously flawed.

"I am in no doubt that the serious and inexplicable omissions in Gary's care contributed to his actions on the evening of 20 September 2020 and his death shortly thereafter."

A spokeswoman for the family said they were "shattered" by the death of "kind" the father-of-three.

She added: "While we're pleased that The Priory has provided evidence to show that it is making the changes needed to ensure that what happened to Gary doesn't happen again, we feel that the provision of basic care should have been in place at the time that Gary needed it most and the fact that it wasn't will stay with us forever."

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