A SECURE mental health unit, which was in charge of Swindon man when he died, has been issued with a warning notice after inspectors found it did not have enough qualified and skilled staff.

Care Quality Commission inspectors visited the Fromeside unit on Bristol’s Blackberry Hill Hospital site, in Fishponds, and were told by employees that they believed the staffing situation was ‘a serious incident waiting to happen’.

Five weeks after the CQC inspection the Swindon man, who was detained on the unit after killing his best friend, was found dead on a railway track after absconding from the care of staff while on an escorted outing.

Michael Harris, 26, who was diagnosed with schizophrenia, was sent to the secure accommodation indefinitely in 2007 after stabbing 23-year-old Carl James to death in Park North.

His mother, Julie Morgan, of Pinehurst, said it was disgusting if staffing levels were low, but she did not blame the staff or the hospital for his death as he was intent on taking his own life.

She said: “I know when he used to go out in the community it used to be two [nurses] but I don’t know how many it was on the ground with him, whether it was one or two.

“We knew he was going to kill himself at some point because if someone wants to kill themselves, they will find a way, and I don’t really blame the hospital. I thought the care they gave him was good.”

Avon and Wiltshire Mental Health Partnership, which runs the unit, has been given a week to report back to the health regulator.

Inspectors found that because there were not enough staff on the unit patients did not always get the care or treatment they needed. They found planned community leave was regularly cancelled or disrupted because there were not enough staff to escort them, causing “disappointment, frustration and anger”.

A spokesman for the trust said the CQC report referred to service users facing reduced levels of escorted leave due to staffing, whereas Mr Harris was on escorted leave, so the two issues were unrelated.

In a statement, the trust said it had taken immediate action to address the CQC’s concerns, adding: “The very specialist nature of our forensic services and the need for us to ensure we have experienced and highly trained staff in this environment has and will continue to be a challenge.

“We recognise that where staffing levels drop or are changed to address other security priorities on the Fromeside site, this can and did impact on our ability to provide some planned escorted community leave, and the trust is working to ensure any cancellations are kept to a minimum."