THE family of a man who died at Stonebow in Hereford say he was "let down" after the NHS Trust admitted a series of procedural failings in the days leading up to his death.

Chris Bowen, 48, died while taking a bath at the Stonebow mental health unit on April 30, 2014, after voluntarily admitting himself to get medical help for serious depression.

He had been a patient at the unit in Hereford for 10 days when he was allowed to take a bath on his own, despite previously telling staff he felt like putting his head under the water.

Mr Bowen had a history of depressive illness prior to his admission and had previously waded into river water on April 18, 2014 which led to his admission to Stonebow. He also absconded from the unit on April 20 2014 and was found near a river.

An inquest into the death of Mr Bowen was held in Hereford in 2015 and a narrative conclusion was recorded.

Mr Bowen’s family undertook legal action against the 2gether NHS Foundation Trust in Herefordshire and Gloucestershire, which has since admitted that mistakes were made.

The case has now been settled with an undisclosed settlement being agreed between the trust and the family.

Lucy Small, of Lanyon Bowdler Solicitors who are acting on behalf of Mr Bowen’s wife, Jackie, said: “The trust has accepted the family’s allegations that there was a failure to assess and address the risk inherent in allowing Chris to have a bath unsupervised, in light of his history and the information given to the hospital staff during his admission.

“There was a lack of communication between staff and information was not recorded which would have been crucial to an adequate assessment of the risks of self harm.”

The inquest heard Mr Bowen told a nurse on April 28 he wanted to put his head under bath water, but this was not recorded in the notes on April 30 of a multi-disciplinary meeting regarding Mr Bowen.

Mr Bowen’s wife, Jackie, said she wanted assurances that such failures would never happen again.

She said: “Chris was acknowledging he was struggling and knew he couldn’t keep himself safe, which is why he admitted himself to Stonebow.

“He was asking for help and he was let down. We were told not to worry and they would take care of him and keep him safe.

“He was at a place where he was supposed to be kept safe and cared for, but instead it was where he died.

“He was a caring husband and loving father to our two children.”

A spokesman for 2gether NHS Foundation Trust said: “Our chief executive, Shaun Clee, and then medical director, Dr Paul Winterbottom, met with Mrs Bowen on May 23, 2014 and offered their condolences and apologies following the death of Mr Bowen whilst in our care.

“We would like to reiterate that apology and extend our deepest sympathies again.

“Following Mr Bowen’s death, we carried out a Serious Incident Review in line with national policy and best practice to examine the circumstances in this tragic case.

“Following the Serious Incident Review, in August 2014 Dr Winterbottom offered to meet with Mrs Bowen to share the findings and actions, and hear her response."

He added: “The safety and welfare of our service users is at the forefront of everything we do and the findings from the Serious Incident Review have been used to inform our service provision, care planning and practice, with the aim of ensuring that we reduce the likelihood of such a tragedy happening again.”