A grandfather who died of cold after walking out of Harrogate Hospital in a confused state was “neglected” by those who were supposed to be caring for him, a coroner has said.
Retired policeman Graham Roskell, whose disappearance in November 2012 sparked the biggest missing person search the town has ever seen, was found dead in woodland near Wetherby 11 days later.
It’s since emerged he was suffering from sporadic Creutzfeldt-Jakob disease (CJD), which left him anxious and disorientated as he tried to find his way home to family in Kirk Hammerton.
A coroner in Harrogate has today (Thursday) said that “gross failures” in the 65-year-old’s care, which allowed him to walk out of the hospital alone despite his confused state, contributed to his death.
“Mr Roskell was an extremely vulnerable patient,” said coroner Rob Turnbull, questioning why recommendations for one-to-one care were not acted upon by hospital staff.
“If he were to leave the ward he would be at risk, given his lack of understanding,” he said. “He should have been detained, which the staff at the hospital failed to do.
“The failure to act on one-to-one recommendations was, in my view, a gross failure. There’s a clear link between this gross failure and Mr Roskell’s death.
“I do find there was neglect in this case.”
Not only had Mr Roskell been allowed to leave the hospital, the court heard, but in a “serious” security breach he had also been admitted access to two supposedly secure wards on his way out - including the special care baby unit and the children’s ward.
“There’s no doubt the hospital was busy,” said the coroner. “It was full to capacity and staff were very busy.
“But action should have been taken to act on the recommendations of one-to-one nursing.”
Mr Roskell, a father of three and grandfather of three more, had first been admitted to Harrogate Hospital on October 29, 2012.
He was anxious and confused, witnesses said, and had once pulled out his drip as he declared he was escaping.
One psychiatric nurse, the day before he disappeared on November 3, had tried to escalate his care as she was concerned about him leaving.
“She made the decision that Mr Roskell lacked the capacity to make his own decisions,” said the coroner. “She spoke to staff and indicated that she would recommend one-to-one nursing.
“The response to that was that it would not be available given the staffing levels at that time.”
Mr Roskell was last seen on the ward at 7.35am on Saturday, November 3, 2012. He was reported missing nearly an hour later.
The search that followed, led by his distraught family, was the biggest in the town’s history.
Hundreds of people volunteered to join the search teams as police, helicopters, underwater divers and specialist dogs scoured the land between Harrogate, Wetherby and Kirk Hammerton.
But despite their efforts, Mr Roskell’s body was discovered in woodland near Wetherby 11 days later. It is believed he had died some days earlier, after suffering hypothermia.
Recording a narrative verdict, Mr Turnbull said: “Graham Roskell was admitted to hospital on October 29 with progressive symptoms of confusion and anxiety.
“He was identified as at risk. Measured were identified to minimise the risk of leaving which were not actioned upon as a result of neglect by hospital staff.”
“We would like to thank the coroner and the trust for accepting that Graham was neglected whilst in the care of Harrogate Hospital, and that there was a serious breach of security by hospital staff, allowing him to enter unchallenged into the secure children’s ward,” said his family after the inquest.
“We are glad that the evidence has now been heard as listening to it all again clearly brings back painful memories.
“This has devastated our family and over a year later his is still in our thoughts daily and we miss him immensely.
“We would like to thank the police, our police family liaison officers, the general public for their support and our legal team.”
Dr David Scullion, medical director at Harrogate and District NHS Foundation Trust, said: “We would like to express our deepest condolences and sincere apologies to the family of Mr Roskell. We accept the findings of the coroner and acknowledge his conclusion.
“Our investigation into the death of Mr Roskell has led to a number of initiatives to improve the safety of patients, which we consider to be of paramount importance.
“We have already increased the number of nurses working on wards that care for elderly patients, where people who are confused are most likely to be accommodated, and addressed the security issues arising from this tragic incident.”