SOCIAL psychiatry professor Rob Poole believes Adrian Kowalik shouldn’t have been allowed to leave Great Western Hospital just hours before his death, an inquest heard.
Prof Poole was called to Salisbury Coroners’ Court for the second day of the hearing looking into the death of Mr Kowalik, 30, on June 19, last year.
Mr Kowalik died at around 5pm, after being hit by a train near Swindon Station.
He’d been at GWH since June 17 after he caused a 4cm wound to his left wrist when his wife Joanna said the couple needed to have a break.
The injury Mr Kowalik suffered was considered superficial but he was kept at the hospital as staff were concerned for his mental wellbeing with him threatening to commit suicide.
Between June 18 and 19 Mr Kowalik, originally from Poland, underwent three assessments before being discharged as there were no legal grounds to detain him.
It was recommended that he attended Applewood ward, at Sandalwood Court, for a three day assessment but he was under no obligation to go. He left GWH at 3pm.
“Given the information available at the time, I would have recommended detainment and I can say that with some certainty as I have done that in the recent past," said Prof Poole, who works at Bangor University.
“I’d have needed more time to understand and it might have changed everything.”
Mr Kowalik, who’d twice previously self-harmed, suffered abuse as a child from his father but didn’t want to discuss it at GWH.
Prof Poole said that mental health staff should have contacted his mother for more details to help them reach their conclusion and decide whether Mr Kowalik had a mental disorder, while also seeking a consultant psychiatrist’s guidance.
Dr Sammad Hashmi, a consultant psychiatrist for Avon and Wiltshire Mental Health Trust, who oversees Swindon’s services, led a review following Mr Kowalik's death.
He said: “In this situation the risk was identified and people knew as the assessment went on that a comprehensive assessment was needed. I think after this they did feel there was neither evidence of a disorder or illness and let him go.”
The inquest, overseen by David Ridley, Swindon and Wiltshire coroner, heard the Kowaliks had married in 2005 and moved to Union Street, in Old Town, in 2007 with their two children.
After suffering a severe back injury, Mr Kowalik, gave up work in 2011. He would occasionally get abusive towards his wife after drinking alcohol.
The inquest continues.