Retired firefighter, 54, was found hanged in his windowless room

A retired firefighter who took his own life whilst being treated at a hospital for severe PTSD was found in a windowless room with just two chairs and a settee which he slept on, an inquest has heard.

Health officials at the Countess of Chester Hospital have been condemned by a jury after former fire station manager John Pratt, 54, was found dead after slipping out of a tiny side room at the mental health facility unnoticed.

His partner Janine Carden had earlier pleaded with staff to keep an eye on him after he been expressing suicidal thoughts, but a nurse told her she had '50 other patients to look after.'

Mrs Carden went home to sleep and returned to the facility the following morning to find Mr Pratt was not in the room and had taken his own life. 

Mr Pratt, who lived with Miss Carden in Frodsham, Cheshire, had been a senior fire officer with the Greater Manchester Fire and Rescue Service at Bolton but had been haunted by his harrowing experiences of dealing with 999 call outs. 

His PTSD deteriorated when he was assigned to move the bodies of casualties who died in the Covid-19 pandemic and he took early retirement.

Inquiries revealed that hospital staff had failed to correctly identify Mr Pratt's high risk to himself whilst carrying out an assessment on him. 

The inquest was also told that no checks or observations were made of Mr Pratt despite there being a policy in place requiring this.

The panel found that there had been a 'complete and total failure to provide basic care' to Mr Pratt and listed various failings including lack of communication between teams and a 'lack of action' by staff in the 48 hours before his death.

Miss Carden said in a statement: 'John was one of life's helpers but did not receive the help he really needed - and this tragically led to his death. His death identifies serious flaws in the care of vulnerable mental health patients who are at risk of self-harm.'

The tragedy began to unfold on Friday September 9 last year when Mr Pratt had a severe episode of psychosis at the wheel of his car when he and Miss Carden came across a police incident whilst they were out on a shopping trip.

Miss Carden told the hearing: 'He was very frantic and he wrote his children's names on a piece of paper when he was driving which is not something he would do. He started to say we were being followed and that something was going to happen and said he intended to take his own life that night.

'He said that it would be better for me and his children if he did that. I told him we were going to get help. I took him to A&E.'

Mr Pratt was seen by a triage nurse and it was agreed he required admission to a mental health unit - but there were no available beds and he was put in the tiny side room.

Miss Carden said she was initially told her partner would get medication at 6pm but it was not administered until four hours later during which time Mr Pratt's paranoia started again.

She eventually decided to go home to get changed and fetch a cardigan and blankets for them both whilst he was left to sleep on the sofa.

She added: 'I asked the nurse if someone could sit with him while I went home but she said 'no' and that she had 50 people to look after. I think the day got the better of me and I just cried saying: "Please can someone sit with him. He might leave the hospital and do something." She just looked at me whilst I am just standing there sobbing and she said the best she could do is get security.

'A security guard came and I just remember being impressed that he seemed to be taking more care of John than the actual medical staff.'

The hearing was told a member of staff at the organisation Independent Support Living (ISL) turned up to check on Mr Pratt the next day but then left again saying he had to tend someone else.

Miss Carden said: 'We did not see anyone except one cleaner who suggested I go to Argos to buy a camp bed. She said it's not very nice for him sleeping there.

'I asked if there was not a bed could he have a trolley that night that they put patients on so that he could lie flat but again they said "No".

'On the Saturday I waited until he had his medication and was asleep. I told the nurse I was going to go home and that if he wakes up for them to ring me and I would come straight in. She said: "That's fine. We know he is a high risk. Security know that he is a high risk."

'I went back in the morning and the reception buzzed me through. I walked up to the room that he had been in but he was not there. I asked the nurse where he was and she disappeared. An A&E consultant came and I could tell by her face that something bad happened.'

The hearing was told proper support for Mr Pratt was only in place between 8:30-9:30am on Saturday, September 9, and it was removed due to a lack of staffing.

A support worker had raised concerns to his management and with Psychiatric Liaison Team (PLT) staff from Cheshire and Wirral Partnership NHS Foundation Trust (CWP) as he did not feel it was safe to leave Mr Pratt.

But no assessment of John's risk to himself was undertaken before support was removed, and no plans were put in place to replace that support.

Lawyers for Mr Pratt's family said they were 'very disappointed' about the quality of the evidence given by CWP staff at the inquest.

They said it was clear that, unlike the Countess of Chester Hospital emergency nurses, members of CWP staff had not reflected or learned lessons following the tragedy.

Alice Wood of Farleys Solicitors who represented the family said: 'No one in John's position should have been left in the way he was, which is demonstrated by the jury's finding of neglect.

'We are grateful for the detailed consideration of the inquest evidence by the Coroner and the jury, which has highlighted that there is a lot of learning required.

'It was concerning to see that some of the witnesses didn't seem to grasp the importance of the missed opportunities highlighted to them.'