Peter Anthony Newman, 33, was discovered asphyxiated on 20 January this year with a plastic bag, secured with a neck tie, over his head, at AMI Kneesworth House psychiatric hospital, near Royston, Hertfordshire.
Mr Newman had made numerous suicide bids during the previous 12 years, including jumping twice from buildings. Before his admission to Kneesworth, he had drifted between homelessness, prisons and hospitals. His compulsorily detention was for his own safety.
Dr Stephen Lomax, Mr Newman's psychiatrist at Kneesworth, told South Cambridgeshire Coronor's Court they had 'assessed him as a continuing suicide risk'. However, no staff witness was able to say how Mr Newman came by a large plastic bag. Anne- Marie Paul, a staff nurse, who found Mr Newman unconscious, said that it resembled a laundry bag. She said that she had tried mouth-to-mouth resuscitation and cardiac massage, but she should not revive him. She had checked on Mr Newman twice during the previous hour.
Michael Bennett, a charge nurse, said that the hospital forbade patients access to plastic bags. Since Mr Newman's death, net bags had replaced the plastic version for laundry.
However, Joy Newman, the dead man's mother, told the court that after her son's death a nurse delivered his clothing in two plastic bags. Mrs Newman said the nurse admitted that patients were given plastic laundry bags.
Mrs Newman said that she had warned the hospital that her son planned to kill himself after she had to cancel a hospital visit because of illness. She believed that her son was depressed. 'When he went to Kneesworth he said, 'Mum I feel safe. Why can't I stay in one place for long enough?' ' she told the court.
Jerry Westall, of the National Schizophrenia Fellowship, said: 'If the Government is serious in . . . its objective to reduce suicides for people with severe mental illness, it must learn the lessons from Peter Newman's case.'