'You gave his family no opportunity to be involved at the most crucial time': Coroner scolds Northampton hospital who discharged patient without telling family

Berry Djebli, 43, was found dead from "a cocktail of his own medication" in his care flat in Spencer Street just four days after he was discharged from Berrywood Hospital.

At Mr Djebli's inquest yesterday (November 7), the coroner heard how Berrywood clinicians sent the patient on his way at 4.30pm on a Friday - leaving little time to make proper arrangements for his care at home.

The hospital also failed to follow all the steps of a "checklist" used when discharging patients after deciding it was "in his best interests" to leave the ward.

Mr Djebli was discharged after an incident on February 12, 2016, on the hospital's Cove Ward where he tried to kick down a staff door. The nursing staff called the police.

It came after an earlier incident when he smashed vending machines in the hospital canteen with a chair.

Dr Krishna Yathiraj, a psychiatrist at Berrywood Hospital, said in evidence: "Please understand that [that Friday afternoon] was a crisis on the ward. I had to make a decision. I saw no deterioration or relapse in his mental state. I believed he was fit for discharge."

But coroner Jacquline Devonish questioned the hospital's decision to discharge Mr Djebli "last thing on a Friday," when he was due for a formal discharge meeting in less than a week's time.

She said: "Do you think that William Tarry House [where Mr Djebli was discharged to] had a chance to prepare for him at 4.30pm on a Friday?"

Dr Yathiraj said: "It was a crisis and we had to act."

Mrs Devonish said: "Was there an alternative option to discharging him, such as holding him as an informal patient until his meeting the next week?"

Dr Yathiraj said: "Having him remain as an informal patient puts him in a position for similar incidents over the weekend."

Mrs Devonish asked: "Do you not think the family should have been involved in the discharge process? You gave them no opportunity to be involved at the most crucial time.

"He was discharged at 4.30pm on a Friday without his family being aware, without his care coordinator being involved and without William Tarry being given details except for a late phone call to say he was on his way."

Dr Yathiraj said: "Hindsight is a wonderful thing. It's something that I have reflected on but the circumstances on that day were quite pressing and action had to be taken."

Mr Djebli's inquest concludes today (November 8).