Serious case review concludes that 15-year old was failed by Hampshire Hospital | Fieldfisher
Skip to main content
Select location
Insight

Serious case review concludes that 15-year old was failed by Hampshire Hospital

A man with curly hair wearing a light blue collared shirt and a dark blazer stands in front of a blurred background of a window view. He faces forward with a neutral expression.
Mark Bowman
01/06/2015
A case review carried out by Devon Safeguarding Children's Board has concluded that 15-year old George Werb was failed by The Priory hospital near Marchwood after a catalogue of errors led to the hospital allowing George to go home for the weekend. Hours after George was released he tragically stepped in front of a train. George had been battling depression and was suffering from delusions that his medicine was damaging him. The case review concluded that:

  • Inadequate records were taken by the consultant psychiatrist following consultations with George

  • A risk assessment had been incorrectly written changing George's suicide risk from YES to NO the day before George died

  • The management plan did not have any note of current or past risk of self-harm or suicide the day after George had made a suicide attempt

  • A staff meeting had concluded that George posed "no current risk of suicide" two days before he died, contradicting a report given a few days before which noted that George had woken up in a low mood and had felt suicidal
The Safeguarding Board is obtaining assurances from all agencies involved in mental healthcare for young people and children to ensure a more cohesive and responsive service, including more money spent in early help services to identify issues sooner.

Mark Bowman of Fieldfisher is acting for George's family.

You can read more about how this story developed here and here

You can read more about this story in the Daily Echo