By Tony Gardner WEST Yorkshire coroner David Hinchliff has slammed serious health and safety flaws in a Leeds psychiatric ward after hearing the latest in a series of fatal cases.
In a Leeds inquest a jury had heard how a seriously mentally disturbed patient was able to walk out of the Becklin Centre at St James's Hospital and throw himself under a train.
Not for the first time, Mr Hinchliff condemned the open door policy in operation at the centre at the time.
In May 2003 former bus driver Kevin Hackney lay undiscovered for four days after killing himself in the bathroom of the centre.
His body was only found when another patient complained he couldn't get in and reported a nasty smell.
Staff found 46-year-old Mr Hackney lying in a pool of blood having cut his throat with a razor blade.
An inquest heard that workers on ward three at the Becklin Centre had reported Mr Hackney, of Rodley, Leeds, missing to the police four days earlier.
Mr Hinchliff said at the time that the search carried out by health support worker Leroy Sanford was woefully inadequate.
He also said that the pendulum in the balance of personal freedom against risk had "maybe swung too far".
Just a week later patient Geoffrey Martin, 56, from Tingley, left the ward and jumped to his death from a tower block.
Then Mr Hinchliff urged health chiefs to step up security. He said: "I still consider that tragedies of this nature will occur time and time again if this particular issue is not addressed."
A spokesman for the mental health trust said it would now carry out a review of security at the Becklin Centre.
The hearing was told that Mr Martin, who lived in Wakefield, suffered from depression and anxiety and had expressed suicidal thoughts.
He was admitted to the unit after taking an overdose at the end of April last year.
The inquest was told that the block of flats that he plunged to his death from could be seen from the Becklin Centre.
In July 2005 a random search of a man's room in the Becklin uncovered three knives – just a day before he nearly stabbed a young Leeds nurse to death.
Schizophrenia patient Mark Bullock knifed nurse Glenda Trinidad and is now serving an indefinite sentence in a secure hospital after admitting wounding with intent to commit grievous bodily harm.
He had a history of knife-related violence, including a number of attacks on police officers and nursing staff, several of them women.
The court heard Bullock had been released from prison just three weeks before he attacked Ms Trinidad.
A spokeswoman for West Yorkshire Strategic Health Authority said: "Leeds Mental Health NHS Trust is undertaking an independent external review of the case and will ensure any lessons learned are implemented."
This year 18-year-old Christopher Fletcher, was found dead in bed at the centre from a suspected overdose. His family insisted he should have been housed and treated in a secure unit until he was well enough to look after himself.
Christopher was living in the Becklin Centre where he had admitted himself while waiting for permanent home.
He had his heart set on a place at a residential centre, and had told his family he was determined to "sort his life out".
But, just two days later, he was found dead in his Becklin Centre bed.
The cause of his death is not yet known, but his family suspect he suffered a reaction or an overdose from drugs.
His father, also called Christopher, said: "Chris was very ill. He thought people were after him and he believed someone called Kylie was following him all the time.
"He needed proper help, 24-hour care. Instead he was passed from pillar to post, no one seeming to want to take responsibility."