by Howard Williamson LEEDS Coroner David Hinchliff challenged the open-door policy of a psychiatric unit after a patient walked off the ward and leapt to his death.
He recorded a verdict that Geoffrey Martin, 56, retired production controller, of Lee Grange Hostel, Westerton Road, Tingley, Wakefield, killed himself when he fell from the balcony of a tower block last June. He was a patient at the Becklin Centre at St James's Hospital in Leeds.
The inquest heard that Mr Martin jumped from a high balcony at nearby Ferriby Towers.
Mr Hinchliff said: "It does concern me that a patient can walk off the ward unseen. I accept that to have a closed-door policy would be draconian and would go against the established view of making such hospitals welcoming and accommodating and useful for the treatment.
"But whenever there is a risk and danger to patients, some discreet system of surveillance should be considered. It is not an easy task and I don't expect people to have a magic answer.
"But I think tragedies of this nature will occur time and time again if this issue is not addressed."
Peter McGinnis, director of nursing for Leeds Mental Health Teaching and NHS Trust, told the hearing: "Many service users have complained their rights have been contravened by observation or by people entering their rooms and we struggle with this dichotomy between rights and choice and professional practice.
"We have, since this death, taken another look at privacy and dignity and we have slightly altered our policy and become a little stronger towards safety and therefore, to some extent, have taken less concern about privacy and dignity.
"But the only way to have stopped Mr Martin was to be close enough to stop him and that would require intensive observation.
"If we lock doors we can reduce the number of people leaving our units who may be intent on killing themselves.
"But the lobby we would get nationally and locally over freedom and liberty would be somewhat high, particularly from those people who don't have these intentions."
The coroner heard that Mr Martin had been treated for anxiety and depression for several years and had made several attempts to kill himself by overdoses and by threatening to hang himself from a bridge.
He was admitted to the Becklin Centre as a voluntary patient and appeared to be improving. Staff did not feel he needed close observation.
Lindsey Martin, of Horbury, Wakefield, one of his two daughters, said he had contemplated suicide since 1999. "He was paranoid about not being liked," she said, "and was very afraid he would be sent away from the hospital on his own."
She questioned why no member of staff was present at the exit to see him leave.
After the hearing, she said she and her sister Stacey were very satisfied with the coroner's statement.