"The trust failed me and my son"

My late son was an in patient at Humber Centre, Willerby. He committed suicide in 2007. It came to light at the inquest that the night before he died he received a visit from one of his solicitors pending early release. I learned at the inquest he was not approached by any member of staff after his visit even though it was said that he seemed disturbed. We also learned the senior member of staff left the ward that night to go to another ward leaving two people who I don’t feel took their job seriously. The events of that night lead me to believe that they did not think to check on my sons state of mind following his visit. He was found hanging in the morning.

Staff were aware that my son was always popping at the window asking for a light for his cigarette. I cannot understand why they did not stop to think, after a considerable amount of time, that he never appeared. I presume they were otherwise occupied. From what I understand, he was not checked that night at all. One of the members of staff said “it could have been anyone” but it wasn’t, it was my son.

The jury came to the conclusion that if the sufficient and correct observations were carried out that night my sons death could have been prevented. I feel the right decision was not reached and we as a family were treated unfairly.