A decision to allow a teacher limited unescorted leave from a mental health ward where he was a patient, had not been properly communicated to his family or nursing staff, a coroner has ruled.
Scottish hockey international Graeme Mutton was last seen leaving the Peter Hodgkinson Centre in Lincoln on November 24, 2015.
The 41-year-old’s body was found four days later hanging from a tree at the nearby Greetwell Road quarry in Lincoln.
Following a four-day inquest, Coroner Paul Smith ruled that Mr Mutton’s family had not been present at the meeting on November 20 when a decision was made to allow him unescorted leave for one hour.
Recording a narrative verdict into his death, the coroner said the views of Mr Mutton’s family had not been canvassed and insufficient weight had been given to his recent history and risk.
The coroner said insufficient consideration was also given to the withdrawal of his family support by the centre and his fear that he would not be allowed to live with his mother on discharge.
The decision to restrict his unescorted leave to one hour was also not passed on to nursing staff, the inquest heard.
And his departure from the ward on November 24 was not recorded in the visible ward log.
The inquest also heard an incorrect note recording Mr Mutton’s return to the ward was also made, with the unit’s missing person protocol not implemented for almost 10 hours after he went missing.
But the coroner concluded it was not possible to say if these matters had any connection to his death.
The inquest was told the Lincolnshire Partnership NHS Foundation Trust acknowledged to Mr Mutton’s family that communication regarding his unescorted leave was not as it should have been, and that once he went missing the incident could have been escalated earlier.
But it was the view of his family there was not enough evidence to know if an earlier realisation that he had gone missing could have made a difference.
After recording his narrative verdict, the coroner said he had yet to decide if he would make any formal recommendations following the inquest.
Mr Mutton, from Market Deeping, was a maths teacher at the Thomas Deacon school in Peterborough and had also worked at the Deepings School and in Birmingham.
In a statement, Graeme’s father Hedley Alan Mutton, said his son came from a close family who supported him throughout his illness.
The inquest heard he separated from the mother of his son in 2008 and was first referred to mental health services in that year.
He married a new partner in 2012 but that relationship broke down in 2014.
The family became concerned about Graeme’s mental health in August 2015 where he was voluntarily admitted to the Peter Hodgkinson Centre.
Mr Mutton said in November 2015 the family were told to “stay away” from visiting Graeme as he had become too dependent on them.
Graeme was allowed two days home leave on November 20 which his father described as “very difficult.”
Mr Mutton said: “He admitted to me he had dark thoughts. I remember Sheila saying he did not have enough medication to stay at home. As we left he ran back in to the house twice to say goodbye to the family.”
The inquest heard Graeme sent a text to his mother, Sheila, on November 23 in which he said there was an 18 month waiting list for therapy.
On the same day Graeme also told a nurse he was worried about his future.
Graeme’s mother received a call at 17.45 on November 24 and was told he had been missing for two hours, the inquest was told.
“We were shocked Graeme was missing and very upset,” Mr Mutton said.
“We were originally told he left at 15.45, later that he left the ward at midday, now we know it was much earlier.”
CCTV showed Graeme leaving the ward at 10.18 and the building two minutes later. Further CCTV at 10.38 showed Graeme buying rope from a Go Outdoors store near to the quarry where he was found.
The inquest heard Graeme was noticed missing at 1pm but no concerns were raised and his phone went unanswered during mid-afternoon. His phone was later found under his bed.
Mr Mutton said although Graeme was not found until November 28, his family believed he took the steps to end his life on 24 November.
Following the inquest, Dr Sue Elcock, medical director at Lincolnshire Partnership NHS Foundation Trust said: “The trust is absolutely committed to providing good quality care and following every unexpected patient death we carry out a thorough internal investigation, including a detailed action plan.
“We have made considerable change following this incident in terms of working with our staff to strengthen our risk assessment processes, ward handovers and our visible nurse and patient leave protocols.
“Clear and continuous communication with families has also been highlighted by this case and our trust systems have already been changed.
“We offer our sincere condolences and apologies to the family at this very difficult time.”