Steven Hart inquest: police and nurses failed

The inquest into the death of 18-year-old Steven Hart, who died 10 hours after discharging himself from a psychiatric ward, finished yesterday at Harrogate Magistrate’s Court after finding failures by police and nursing staff.

Hart died on the A1 in September 2002 after discharging himself from Friarage Hospital, Northallerton, North Yorkshire. He wandered on roads lost for nearly 10 hours, without any money or means of transport, in an attempt to get back to his home town of Harrogate.

Hart’s family said they were “very appreciative” of the “extensive” investigation carried out by John Sleightholme, deputy coroner, but found that witnesses had “unsatisfactory responses” to questions from the jury because the inquest was held five years after Hart’s death.

In a narrative verdict, the jury raised concerns over the way in which Hart was discharged from hospital, without clinical or evaluation notes from nursing staff.

It noted that the police failed to question Hart, when they picked him up and set him down on the A61, an unlit road with no path. 

The police also failed to connect the four 999 calls from concerned motorists over Hart’s behaviour on the roads the evening he died.

Deborah Coles, co-director of INQUEST, which legally represented Hart’s mother, said: “This case raises all too familiar systemic failings during the treatment and care of a vulnerable mentally ill teenager. Such tragic deaths must be rigorously and promptly scrutinised to ensure lessons are learned.”

Coles added: “A five-year delay frustrates the learning process and the opportunity for safeguards to be put in place to protect the lives of vulnerable people in the future.”

Hart, who had a history of paranoid schizophrenia, agreed to be admitted to Harrogate Hospital by his family two days before he died.  But once admitted he was transferred to another hospital 28 miles away, without his family’s knowledge, as there were no beds available.

His condition stabilised on the 26 September and Hart sought to discharge himself, but as transport could not be arranged immediately, he asked the nurse to show him the exit and he left the hospital.

Over the next 10 hours, the police received four calls from motorists who were concerned over Hart’s behaviour as he walked down the AI and A61 in North Yorkshire. He was later killed, walking naked in the opposite direction of the traffic on the fast lane of the northbound A1 carriageway.

More information

INQUEST, an organisation which provides free legal and advice services for families of those who die in custody

Essential information on mental health

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