NHS Trust Admits Liability And Apologises After Wife Asks Medical Negligence Lawyers To Investigate

A grandpa diagnosed with psychotic depression after developing chronic pain and mobility problems took his life following “missed opportunities” in his mental health care. 

Steve Dance, of Leicester, had a two-year history of low mood and chronic pain, after an injury to his left Achille’s tendon.   

After medical examinations ruled out physical causes for his pain and decreased mobility, he was placed under the care of mental health services and assessed for his low mood and psychosomatic symptoms. 

It was deemed Steve, who would cry and shake in pain, who complained of and became fixated by reduced blood flow to his legs as well as leg pain and who had started to not leave the house, should be cared for in the community.  

Community psychiatric nurse didn't see Steve for at least four months despite planned fortnightly visits 

However, a community psychiatric nurse did not visit Steve and wife Carol for at least four months. When Carol sent a text to the nurse raising concerns about her husband’s deteriorating health and he was saying daily that he would be “better dead sooner” the message was not shared or discussed with anyone for eight days – the day the 68-year-old died - an NHS investigation found. 

Family of Leicester man Steve Dance asks medical negligence lawyers to investigate

Following the father-of-one and grandpa-of-three’s death, his family instructed expert medical negligence lawyers at Irwin Mitchell to investigate his care under Leicester Partnership NHS Trust. 

Carol, aged 69, is joining her legal team in using World Suicide Prevention Day to speak for the first time about her loss and is calling for lessons to be learned to improve mental health care. 

It comes after the Trust admitted liability for Steve’s death and apologised for “the substandard care” he received. 

A serious investigation report by Leicestershire  Partnership NHS Trust found there were “a number of missed opportunities in ensuring Steve received timely and appropriate care within the community.”

Kayleigh Hunter is the specialist medical negligence lawyer at Irwin Mitchell representing Carol.

Expert Opinion

“The past few years and trying to come to terms with Steve’s death and the events surrounding it have been incredibly difficult for his loved ones.

“Sadly a number of worrying failings, not only in the standard of care Steve received but also with communication between those meant to help him, have been identified.

“While we welcome the Trust’s pledge to improve care, it’s now vital that staff are supported to uphold these measures and maintain patient safety at all times.” Kayleigh Hunter

Medical negligence: Steve Dance's story

Steve, a former plumber and amateur footballer, was referred to mental health services in May 2021.   

After he was diagnosed with psychotic depression, he was allocated a community psychiatric nurse.

The nurse first visited Steve on 25 June, 2021, when he complained about leg pain but denied he had problems with his mental health. A plan was made for the nurse to visit every fortnight and Steve would also have regular psychiatrist reviews. 

Carol, who was married to Steve for 46 years, said that the nurse visited again in July and August, and then on 17 September, 2021. While Steve’s notes indicated that he was visited in January 2022, Carol said the visit never happened. Despite Carol saying she was chasing for an appointment, the next visit was on 16 March, 2022 

During 2021 Steve also attended a number of psychiatrist appointments and his medication was increased several times but there was no improvement in his condition. 

When the community psychiatric nurse visited on 16 March, Carol, who was increasingly concerned about her husband who had not properly eaten for six weeks, asked for him to be admitted to hospital.  The nurse’s notes were only recorded on Steve’s medical records after his death.   

On 29 April, 2022, Carol sent a text to the nurse concerned about Steve and that he was saying daily that he would be better off dead. However, there was no evidence that the text was escalated to a consultant psychiatrist or senior clinicians to consider Steve’s immediate risk. 

Steve was found hanging on 7 May, 2022, and pronounced dead shortly afterwards. 

Health Trust's investigation also finds series of issues in Steve's care

Leicestershire Partnership NHS Trust’s investigation report concluded Steve’s care issues included:

• There was no evidence of considering further anti-depressant medication or other treatment to help improve his mental health.

• No evidence a psychology referral had been discussed to consider alternative treatment.

• Steve wasn’t visited by a community psychiatric nurse for at least four months.

• There was no documented evidence of regular discussions between the consultant psychiatrist and community psychiatric nurse regarding Steve’s care and treatment.

• There were missed opportunities where Steve should have been directly asked about his suicidal thoughts.

• There was no evidence that hospital treatment for Steve was considered throughout his care under mental health services.

• There was a lack of application of knowledge and consideration of his symptoms.

• There was no evidence Carol or Steve were advised about urgent care options after Carol raised concerns her husband wanted to take his life. 
 
In the report the Trust said it has implemented changes including ensuring community psychiatric nurses’ duties and absences are covered and clearly recorded and discussions between staff being clearly documented. 

Carol pays tribute to loving family man Steve as she calls for improved mental health care

Carol said: “We met when I was 16 and Steve 18 and got engaged on my 17th birthday. Everyone told us it wouldn’t last but we knew we’d be fine. We had bumps in the road but we were meant for one another. 

“Football was Steve’s passion. He played for various teams on a weekend until he was nearly 40 while our favourite family days were around with Steve’s other hobby of aviation and air shows. He loved history of the First and Second World Wars and must have read hundreds of books. 

“Steve couldn’t sit still once his eyes opened and he was out of bed. That’s why it was so out of character when he started suffering with his symptoms. 

“He became a lot more withdrawn and disorientated. He lived in pain and would often cry out because of the agony he was in.

“When he started receiving mental health care we hoped it would be the start of his reclaiming more of his old life. However, the months went on and nothing changed. In fact, it got worse. 

“We tried our best to reassure him but he was always saying he would be “better dead sooner”. I still struggle to understand how despite raising these concerns nothing was done to help him. 

“Steve was a fantastic husband, dad and grandpa. He was a loving family man who we all adored. Life is a much darker place without him in our family. 

“It’s difficult not to think that he would still be with us if he received the care he should have. Following Steve’s death I was determined to get justice for him. It’s the least I could do to honour his memory. 

“The last few years and getting all of the answers to our many concerns has taken a toll on all of us. While we take some small comfort from having answers, it is still heartbreaking that Steve is no longer with us. 

“All I can hope for now is that by speaking out lessons are learned to help others. I wouldn’t wish the pain our family have been left to face on anyone.”

An inquest concluded in November 2023 found that there were missed opportunities in the care provided to Steve.

World Suicide Prevention Day is on 10 September.