Father Russell Duncombe 'felt system had let him down'

Senior coroner Grahame Short said Russell Duncombe “had given up hope that his problems could be cured” while also citing a “lack of joined up thinking” leading up to his suicide.

Mr Duncombe had called an ambulance on the evening of October 12 last year. He was taken to Royal Hampshire County Hospital (RHCH), in Winchester, with ambulance staff regarding him a “high risk” of suicide.

But when nurses carried out a handover in the hospital’s A&E department they were not told. Nor was a risk assessment carried out as this was not standard practice at the time.

The 36-year-old escaped from hospital, without telling staff and hanged himself in a nearby woodland.

Pictured: Russell Duncombe

The inquest heard that the Andover resident led a “chaotic” life and had a history of alcohol problems which were worsened by the deaths of his grandparents and his father, who died within a matter of months in 2015.

His mother Donna Duncombe said he “took it hard losing them” and said he became more withdrawn last year as his problems began to escalate.

She said he was “hearing voices” that told him he was “useless and worthless and that he shouldn’t be on the earth” and “that was why he drank”.

After a suicide attempt in March 2018, Mr Duncombe was referred to the mental health team. It was noted that he had some symptoms of depression but he was not diagnosed with a mental illness.

Mr Duncombe tried to end his life again on September 19, attempting to hang himself near Andover police station. He was taken to Southampton General Hospital where he was put on a detox programme, but after a few days he absconded and returned to drinking, the inquest heard.

A plan was put in place for detoxification at a later date, but clinical guidance prevents more than one detox being administered within a six month period.

Mr Duncombe was told to phone an ambulance if he was feeling suicidal and called on the evening of October 12. After leaving hospital, he sent a message to his partner saying: “Busted out of hospital, time to prove a point,” before hanging himself.

In summary, Mr Short said “the clues were there” for the nurse to have been aware of the increased risk, as she knew he had previously attempted to hang himself. He was also intoxicated at the time.

Mr Short added that nobody who was present the night of his death took an “overview of Russell’s problems” and nor did they recognise that his “deteriorating behaviour” could have led to him committing suicide.

However, he also said there was “no clear evidence that if there had been that approach it would have prevented his death”.

He added that “the only way this could have been prevented was if he had been constantly observed in the cubicle” but acknowledged this was not possible as it was a busy Friday night.

Mr Short continued: “His blood alcohol level confirmed he was intoxicated at the time of his death. I think that is relevant in the context of his behaviour.”

He added: “I know his family feel frustrated by the system but the key to his problem was his alcohol dependency and only he could face up to that, I believe, and to take advantage of the help given to him.”

Speaking after the inquest, Mr Duncombe’s partner, Joanne Rogers said: “He should still be here.

“Everyone turned a blind eye. He said, ‘I’m just a statistic that you can write off your list’ and he was right. He was ignored.”

She added: “He’s got six kids without a dad now.

“How do you move on when he died and take your heart?”

Hampshire Hospitals NHS Foundation Trust was contacted for a comment following the inquest.

Chief nurse Julie Dawes said: “This is a very sad incident and our thoughts are with the family and friends of Mr Duncombe at this difficult time.

“We carried out our own comprehensive investigation into the circumstances surrounding Mr Duncombe’s treatment and have already made changes to improve the way we care for patients in this situation.”