QUESTIONS have been raised about care at the Stonebow Unit in Hereford after a man was found dead in the clinic's garden.

Patrick Dara Mullin, who was known as Dara, died aged 51 on August 14 last year.

Herefordshire Coroner's Court heard that Derek Hale was visiting a family member at the mental health unit next to Hereford County Hospital and was in the garden when he discovered Mr Mullin and raised the alarm.

Mr Mullin, who lived in Allensmore, was pronounced dead at the scene and a post mortem gave the medical cause of death as ligature around the neck.

The inquest heard that Mr Mullin was a voluntary patient and had been to see his GP and asked to be admitted to Stonebow on August 2 as he was having suicidal thoughts.

He had been assessed as high risk of suicide when he entered the unit, but as time went on this could have been assessed by staff at the unit as they got to know him.

Mr Mullin was on what is known as L60, which means a member of staff observed him every 60 minutes and ticked a chart if they had seen him. He was also allowed to leave the unit.

Qualified psychiatric nurse Liam Craig told the inquest that on August 14 Mr Mullin was not observed at 4pm. Mr Craig was agency staff and thought Mr Mullin was low risk due to the level of observation. He talked to other staff and decided that if Mr Mullin had not returned by 7.30pm he would be reported missing.

Mr Mullin was observed by a member of staff at 5pm but at around 6pm he was found dead.

Coroner Mark Bricknell said he did not like that there is a 60 minute observation rule but then this appears to be flexible.

Dr Christopher Fear, who was medical director of 2gether NHS Foundation Trust before retiring in December, carried out a serious incident review and made a number of recommendations - one of which means that there is now further information on each patient on what to do if they are absent during the observations.

Dr Amjad Uppal, current medical director, said: "In a practical world it is sometimes really difficult to to hold people down to the minute. There are lots of people who are at high risk of suicide who manage very well in the community and are not under any observations at all."

He said the closer the observation the more patients struggle.

Mr Bricknell said it was appropriate for him to write a prevention of future deaths report which will be sent to the NHS trust and the chief coroner. He recorded a conclusion of suicide.