The mum and dad of a popular and talented East Devon teenager suffering from severe mental illness who committed suicide by standing in front of a high-speed train within hours of being granted home leave from hospital, said they believe their son would still be alive if it weren't for "incomplete and inaccurate" information used in assessing him.
George Werb, 15, from Colyton, died when he was hit by the train at around 6.50am near Seaton Junction on Friday, June 28, last year.
The inquest at Exeter's Coroner's Court heard that George had left a three page suicide note under his bed which was discovered shortly after the tragedy occurred and his parents, Joanne and Justin Werb, felt his suicidal tendencies were not taken seriously enough by staff at the Priory Hospital in Southampton where he was been a patient for five weeks prior to his death.
The court heard that George was prescribed anti-depressants and had talked to staff nurses about feeling suicidal in the days leading up to the day he was allowed leave but no risk assessment had been carried out on his ability to cope. Hours later he walked in front of the train.
In a narrative conclusion culminating the two day inquest, before praising George's family and passing on her condolences, assistant coroner Lydia Brown, said: "George died on the railway track near Seaton Junction. At the time he was on home leave from inpatient care in a children's psychiatric unit. Before he went on leave he was assessed as having no suicidal risk.
"The information used in this assessment was incomplete, inaccurate and did not reflect the actual situation.
"Poor engagement with the family, having to place him in a unit a long distance from home, absent note taking and inadequate internal hospital communication all contributed to this outcome."
The coroner went on to say: "The way we care for our mentally ill children should amount to the highest standards of care and a service of absolute parity of those children unfortunate to suffer physical ailments – this does not happen.
"Doctor Hoyos could not do his job adequately because of the lack of clinical support, and the therapeutic service suffered the same, the community could not place in him locally because there were no beds."
Ms Brown confirmed she would be writing to the commissioners in Devon, NHS England and copying in the Department of Health outlining her concerns.
In a statement George's parents said: "Losing George has been an unimaginable loss to our family; our pain has been unrelenting beyond expression. George was not only a son, but a brother, grandson, cousin and friend.
"We remember George's incredible life, his amazing achievements, his jovial personality, his very quick wittedness, his integrity, his beautiful smile, his contentedness, but above all we remember his absolute love of his life and his imperative place in our family.
"Living with George brought entertainment to us on a big scale, he was either singing, practicing lines, playing music or playing an instrument. He performed in talent shows, singing competitions, Oliver, and played the role of Bugsy in Bugsy Malone at the town hall, as well as singing in the local church choir and fundraising for the drama club that he belonged. He loved joining clubs and loved his sailing, badminton and karate lessons.
"At school he was a member of the jazz band and gym and received several end of year commendations for progress and attendance.
"He performed in the school's production of We Will Rock You, but George is probably best remembered most for the talent competition when he sang Michael Jackson's, I want you back, in which he won first prize.
"George had aspirations, he wanted to work at the Globe Theatre, either in performing arts or some other job, but it was one of his ambitions. He loved music and wanted to join a rock band. He loved cycling and coming home to tell us that he had found a new path or cycle route. He loved reading about World War One and Two and adventure fiction. He enjoyed school and was on track to achieve high GCSE grades and during May last year and while in hospital, he took biology GCSE and earlier this year we received his certificate and he achieved an A grade.
"So to lose our son of only 15 years who had so much more to accomplish and experience is totally heart breaking and so we continually ask ourselves what did this happen?
"When George asked for help and like any parent we sought professional help for him, we turned to doctors and adolescent mental health services. George knew he was unwell and understood that hospitalisation was necessary for recovery. George did not have a long history of mental illness and nor had he taken any medication but within seven weeks of professional care he took his own life.
"That wasn't an act of bad luck or being at the wrong place at the wrong time. George was in the right place, at the right time, with the right people, all with all the appropriate skills and yet this tragedy was made possible to happen.
"After George died, we blamed ourselves and the decisions we made with him, but having since read the hospital files, statements and George's last letter etc, we now know that George by his own admission did not want to die but to be "saved from himself" as he put it and, at a moment of weakness, at his most vulnerable, during his darkest hour, on a high cocktail of the maximum allowable medication, he sought at that moment, in his confused mind, the only release and way out.
"The findings that the information used to assess George's suicide risk were incomplete, inaccurate and did not reflect the actual situation is upsetting and we believe George would still be here had things been done differently.
"We shall love him and miss him every day for the rest of our lives."
In a statement read out to the court, the train driver said he had applied the brakes and emergency brakes immediately on seeing someone walk "calmly and deliberately" onto the tracks in front of the train.
The court heard that after being referred by his GP, George waited around 10 months until his first appointment with a Child and Adolescent Mental Health Services (CAMHS) team member in Exeter. It was a subsequent visit to his GP who referred George back to CAMHS and the consultant child psychiatrist for CAMHS, Doctor Divik Seth diagnosed him as suffering from psychosis involving persistent delusion disorder with depression, which he described to the court as "exceptionally uncommon".
George's father explained that the family had noticed a change in George around 18 months before his death, and had witnessed him going from being outgoing to becoming withdrawn.
George was initially prescribed anti-psychotic medication which the court heard he refused to take after three doses. George's father explained that they noticed a "massive" change in their son from the point he started taking the medication. The court heard that George was extremely distressed at having taken the medication, having researched the effects on the internet, a trait that persisted in line with his condition, from then on.
He was subsequently advised he needed hospitalisation to ensure his safety and for ongoing assessment and treatment. Dr Seth told the court it was usual for him to have to phone around 20 – 30 units to find out where there is availability for a new patient because of the shortage of psychiatric beds.
The closest unit to George was Plymouth but there was no room, so the closest hospital with availability was at Huntercombe Hospital in Maidenhead which George's parents removed him from after visiting him three weeks later. They said his room was "not fit for a dog", his bed had no sheets on it, the curtains were too short, he still living out of his suitcase and he looked dishevelled and unclean, and discovered another patient had threatened to kill George.
After returning home for a short period, George was sectioned and admitted to the Priory, where staff were "very kind".
Giving evidence, George's parents spoke of their dissatisfaction over the lack of communication from hospital staff particularly that, they say, they were not advised that suicidal tendencies could increase as a possible side effect of the anti-depressants he was prescribed.
The court heard that, in an incident involving a shower curtain, George has tried to take his life at the hospital but his parents weren't immediately informed. And when his mother Joanne informed staff her son was suicidal, after his first weekend visit home after about a month, there were no formal meetings to discuss the issue, nor any real attempt to engage with them and keep them informed.
However consultant psychiatrist at the Priory, Dr Hoyos, who had been seconded to the hospital by the Southampton CAMHS, refuted this point and said he was not informed of George's worsening suicidal thoughts by his parents, only the issue of George's medication making him worse.
During the ward nurses' evidence, the court was told that the day after returning from his first period of leave he had told nurses that he felt suicidal and wanted to kill himself, but despite this being a regressive feature, because he was not presenting any accompanying concerning factors, he was assessed as not being a suicide risk and being fit enough to go on leave again three days later.
The court heard that warning signs of George's fragile state of mind on the day he was due to go on his final leave, were not communicated to his parents, but Dr Hoyos explained that they were documented by staff but he had to weigh the risks of not permitting leave, with the risks of permitting it.
George's mum told the court her son seemed happy in the early days at the hospital but wasn't happy about the anti-psychotic medication being resumed. She said her son told her he would sometimes spit out his medication so it was changed to a melt in the mouth tablets.
The court heard that George had drawn pictures of scenes depicting his suicide and writing which said 'game over young lad', in his school books, which hospital staff claim not to have seen.
She requested that Dr Hoyos reduce his medication but the court heard that he refused, believing it to be a crucial part of his treatment. Dr Hoyos explained that there is no significant evidence that the particular anti-depressants George was prescribed caused suicidal tendencies.
George's father told the court that when he returned home for a weekend he was "far from well" and when he visited him at the Priory his son looked "hideous" and thought his son was getting worse. Dr Hoyos explained that George did not want to be in hospital and became disengaged with staff and refused to go to school lessons.
The court heard that the consultant didn't meet George's parents until a couple of weeks into his five week stay, but he "wished" he had. And a detailed risk assessment of factors relating to George's suicidal thoughts and causes of his distress was not made. However Dr Hoyos was adamant that assessment was ongoing by staff members, but there is no official record of a detailed assessment.
The court heard that Dr Hoyos did not keep regular written clinical notes, an issue that is being looked into by the General Medical Council, but he said this did not affect patient care. He said he preferred a 'verbal handover', but on four occasions references to suicidal thoughts were made in written notes which he hadn't seen. He admitted that he did not have a risk assessment conversation about George prior to his second leave.
It emerged during the hearing that George and his family weren't offered family therapy sessions due to the distance from the hospital to their home.
And Neil Law, the therapy services manager for Southampton said that distance from a hospital impacted on the treatment patients received. He said the issue of the shortage of psychiatric beds was a national problem. He also said there was a difficulty, reflected nationally, to recruit psychology professionals at the ward which, for example, the Priory should have a full time paediatric and adolescent psychotherapist, but the ward has only a sessional part time post.
A spokesperson for the Priory Hospital, said: "Our heartfelt sympathies are with George's family at this difficult time. As with any sad case such as this, we have undertaken a comprehensive internal review and we will now consider and act on the comments of the Coroner."
![Parents of popular East Devon student say their child would still be alive if his suicidal tendencies were taken seriously enough by medical staff]( "Parents of popular East Devon student say their child would still be alive if his suicidal tendencies were taken seriously enough by medical staff")
