SWINDON and Wiltshire Coroner David Ridley said lessons need to be learnt from the death of Adrian Kowalik who was released from Great Western Hospital despite making several threats to take his own life, an inquest heard.
Mr Kowalik, 30, died at around 5pm on June 19 last year, after being hit by a train near Swindon railway station.
Mr Ridley, who oversaw the three-day hearing at Salisbury Coroner’s Court, recorded a narrative verdict. He cited contributing factors to Mr Kowalik’s death to be a failure to assess that there was a risk he’d take his own life, that he had a mental disorder and that he wasn’t duely safeguarded.
Mr Kowalik, originally from Poland, had 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.
Due to his continued suicidal threats he was kept in hospital. From June 18-19, Mr Kowalik underwent three mental health assessments before being discharged as it was ajudged that he was showing no signs of mental disorder or mental illness.
Mr Ridley said: “I find that those directly involved must have known that there was not just a risk of harm but a loss of life.”
It was recommended Mr Kowalik, who had previously self-harmed twice, attended Applewood ward, at Sandalwood Court, for a three-day voluntary assessment, but he refused. He left GWH at 3pm.
Mr Kowalik didn’t speak very good English and communicated through a Polish nurse in his first assessment and a translator in the following two. He was abused as a child but refused to speak about the incident.
On the day Mr Kowalik was released, assessors felt he wasn’t showing any immediate suicidal indications. However, Mr Ridley felt he might have been getting frustrated with the assessment process – a view shared by Mrs Kowalik.
“He was fed up and exhausted and had reached the end. He wasn’t telling them the information they wanted, so they could have asked me,” said Mrs Kowalik.
“I’m still always asking why nobody there called me to pick him up – he would have been safe.”
Mr Kowalik, who absconded from the hospital to the train station on June 18, was brought back by police.
He was offered a lift by GWH, but he decided to walk and didn't tell staff where he was heading when he was discharged.
The Kowaliks 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.
He’d smoked cannabis for two years and had also been dealing the drug.
“Adrian needed more time and I think he chose to end his life too soon,” said Mrs Kowalik. “I miss him very much.”
The inquest heard Dr Sammad Hashmi, a consultant psychiatrist for Avon and Wiltshire Mental Health Trust, led a review into the case and their procedures.
Mr Ridley said he plans to write to the trust to check the progress of improved staff training and providing multilingual leaflets.
“I hope this case can be used as a lesson for training purposes,” Mr Ridley said.
A spokesman for Avon and Wiltshire Mental Health Partnership said: “Our staff made decisions that they believed were in the best clinical interest of Mr Kowalik. In the light of the coroner’s conclusions, we will review the management of Mr Kowalik’s care to ensure we learn from this tragic event.”