On 7th April 2017 commenced an investigation into the death of Matthew Sean Arkle. The investigation concluded at the end of the inquest on Ist November 2018_ The conclusion of the inquest was that; Matthew Arkle died as the result of suicide. Matthew was a voluntary patient at the Wedgewood Unit; West Suffolk Hospital who was granted one hours unescorted leave on the 4"h April 2017 but did not return_ On the morning of 6th April 2017 Matthew was found hanging next to a tree in an area of heath land directly adjacent to the West Suffolk Hospital in Bury St Edmunds He was pronounced dead at scene The medical cause of death was confirmed a8: 1(a) Hanging I(b) 1(c) Schizophrenia and depression_

Matthew Arkle was a 37 year-old man with a diagnosis of paranoid schizophrenia_ He had been mentally unwell for some time and had a number of admissions to hospital under the Mental Health Act (his first in the year 2000) In December 2016 Matthew took an over dose of prescription medication and was admitted as an inpatient until the 1st February 2017_ On the 17th February 2017 he was re-admitted to the Wedgewood Unit; West Suffolk Hospital as an informal patient following a further over dose of prescription medication: the consideration and risk assessment process by the nurse who authorised the unescorted leave. It was acknowledged that this information may not have changed the decision, but it was deemed to be an important factor to take into consideration. It was further acknowledged, that due to Matthew's generally compliant nature, had he been asked not to take unescorted leave that (due to his families concerns) then he may well have remained on the ward of his own choice. Witnesses on duty on the Northgate ward on the 4th April confirmed that were unaware of Matthew's family request regarding leave that Further; there was no written note of the families request on Matthews case file and no witnesses had any memory of it being verbally raised at the ward handover meeting at the start of the shift It was reported that the activity on ward was extremely high on the 4t April 2017. It was heard that although staffing met the required levels, there were a number of patients requiring additional supervision and a high number of 'staff personal alarms' were activated during the shift: The charge nurse on duty said cannot stress enough how busy it was that day" and agreed the ward on the 4th April could be described as being chaotic. In part; this was held to be the reason that Matthew's time of leaving Northgate ward to go on unescorted leave was originally recorded to be 19.00 with the police subsequently alerted to his missing person status at 21.06_ CCTV evidence secured from a local garage in the weeks following his death showed that Matthew must have left the ward no later than 17.30 on the evening of the 4th Aprii. It was subsequently identified that the 19.00 timing had been an 'approximation' with it being agreed 17.30 would be a realistic time for Matthew having left the ward. As such Matthew's unescorted leave should have ended at 18.30 with the alarm being raised for Matthew's absence occurring much earlier than it did: This would have allowed searches undertaken by hospital staff; Matthew's family and the police to commence sooner. It was confirmed during the hearing that in relation to patients going missing, there is no policy in place for a review CCTV footage available at the Wedgewood Unit or the West Suffolk Hospital to confirm time of leaving, direction of travel, etc. This would have clearly provided an accurate time and possibly direction of travel in Matthew's case: It was heard that once the Suffolk Constabulary were informed of Matthew's absence they instigated their missing persons protocol designating Matthew as a medium risk on the basis of the information received from staff at the Northgate ward, On the basis of the information the Suffolk Constabulary received this was found to be the appropriate level when reviewing their risk assessment process However; Suffolk Constabulary were not told that Matthew had seriously attempted suicide on two occasions in the past three months, were not told that his family had specifically requested he not be granted unescorted leave on the 4th April or that on the previous Matthews care coordinator had described him "as the lowest have seen him for some time It was heard that there was no set format for the type or nature of the information to be given to the police when a patient goes missing and what information was available in Matthew's case was incomplete (including no recent photograph) day they day: being being day

In evidence it was heard that had the Suffolk Constabulary been given the above information at the time of his going missing that "in all likelihood" Matthews risk would have been assessed as 'high' . It was then explained that once a 'high' risk had been declared additional police resources would have become available_ This included the immediate deployment of up to 10 police officers to assist in the initial search for Matthew on the night of the 4th April: In relation to the timing of Matthew's unescorted leave it was well documented in his notes that his auditory hallucinations became strongest in the evenings which was often associated with a lowering in his mood. The charge nurse who granted the unescorted leave said that when they did so they could not see any evidence of 'internal stimulation' from auditory hallucination explaining that Matthew did not appear vacant or distracted. However; when coupled to the other identified factors in this case the timing of Matthew's request for unescorted leave was not an identified feature of the risk assessment process prior to his unescorted leave being granted. The jury recorded that the following circumstances may have contributed to Matthews death: - A failure of appropriate record keeping within Northgate ward. A failure of verbal and written communication within Northgate ward. The general high level of activity and stress on Northgate ward on the 4th April 2017. The in noticing, reacting and reporting Matthew as missing: The of Matthews release late afternoon:

In my opinion action should be taken to prevent future deaths and believe you or your organisation have the power to take such action