THE family of man who escaped a mental hospital, fled abroad then hanged himself in a prison cell have said he was let down by Oxford Health.
Ian Mitchell, who was serving a life sentence for stabbing his ex-partner Michelle Storer, walked out of Littlemore Mental Health Centre on July 8, 2013, and travelled 1,500 miles to Poland.
He was detained by Polish police using a European Arrest Warrant on July 15, but hanged himself in a prison cell on August 8 while awaiting an extradition hearing.
At the inquest into the 44-year-old’s death yesterday at Oxford Coroner’s Court, it emerged that he wrote letters to family and doctors from prison saying he regretted the escape.
Some were not delivered until months after he died. In the letters he told how he had already tried to hang himself once in a prison cell and was hearing voices which were “driving him mad”.
The inquest jury was told he was transferred to a prison in the town of Koszalin on August 5 and put in a cell with “interim” surveillance, despite a recommendation from security managers for constant surveillance, because that type of cell was unavailable.
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He hanged himself in his cell on August 8 and died in hospital six days days after that.
Speaking after the inquest, his mother Mary Henderson said Oxford Health NHS Trust, which runs Littlemore, had “a lot to answer for”.
Mrs Henderson, who lives in Mansfield, said: “They let him down and they should be held liable.”
She said her son had run to the Polish seaside resort of Kolobrzeg to meet with a cleaner from Littlemore, who was visiting family.
The inquest held at County Hall heard the woman was fired from Oxford Health after an investigation found she had not met the trust’s standards of behaviour.
The jury was told Mitchell successfully applied for a passport when he was at a previous Oxford Health facility, Marlborough House in Milton Keynes.
Mitchell’s psychiatrist at Littlemore, Dr Rami El-Shirbiny, said patients were not supposed to carry passports in the ward, and said the trust did not know why Mitchell had his.
Coroner Darren Salter said there appeared to be no national guidance for managing passports for prisoners like Mitchell in minimum security mental hospitals like the Lambourn House ward Mitchell was on.
Mr Salter said he would write a report to the Ministry of Justice about it.
He also said he would write to Oxford Health to ask if doctors at Marlborough House knew he had got a passport, and whether they told Littlemore.
Mr Salter read extracts from a letter Mitchell wrote to the governor of Bullingdon prison, where he was formerly held, on August 6, 2013, to say if he was re-incarcerated he hoped it would be to Bullingdon to “sort himself out”.
He also wrote a letter to Dr El-Shirbiny dated July 25, which the doctor said he did not receive until October 31, in which he said: “Firstly I just want to say how sorry I am for walking out of Lambourn House.
“Since then my life has been a nightmare, I’m still having flashbacks, these voices are driving me f****** mad.”
Mitchell told the doctor he managed to get the cleaner’s number without her knowing, but said when he contacted her she was “scared and worried I might hurt her”.
The inquest heard from staff at Littlemore who said when Mitchell first arrived on April 29, 2013, he had been settled, but that all changed at an assessment meeting where he learnt he might have to return to prison.
On the night of July 7, the inquest heard he stuffed his bed with pillows to make it look as if someone was sleeping within. He called a taxi from his mobile phone and got a taxi to St Pancras, where he caught the Eurostar to Brussels, then a train to Poland.
Nurse Lydia Aigbe-Elvis, who was in charge of Lambourn House that night, told the jury she inspected Mitchell’s room at least four times, shining a torch in to check. But she said that system has since changed, and nurses must turn on a night light once every hour to check on the patients during the night.
The trust’s head of low secure services Dr Jude Deacon said the trust had also changed the way it managed passports to tighten controls.
After an inquest which lasted more than seven hours, the jury gave a narrative verdict that Mitchell’s death was caused by his hanging but said: “It’s not certain he intended to take his life”.
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