A MENTAL health patient jumped to his death from a bridge over the M5 motorway near Wellington because carers looking after him had not brought his cigarettes when he was transferred between hospitals.

Daniel Shaw, aged 28, was moved from an assessment ward in Exeter to a privately-run Cygnet Hospital, near Taunton, on December 30, 2020.

However, his cigarettes were left behind and five days later he was taken to a shop to buy more but did not have enough funds on his debit card to do so.

Later in the day, January 4, 2021, Mr Shaw, from Lympstone, Devon, absconded from the Cygnet hospital and jumped from a motorway bridge and was struck by several vehicles.

Somerset Senior Coroner Samantha Marsh concluded his death from multiple traumatic injuries was suicide.

Mrs Marsh said the failure to transfer Mr Shaw’s cigarettes was a contributory factor in his death, as was the hospital’s decision to allow him leave to purchase more instead of taking alternative steps to recover the tobacco for him.

She said the hospital also failed to follow procedures for the section 17 leave which Mr Shaw was granted to go and buy cigarettes, and it was further shown that it was not appropriate for him to have been given the leave, which contributed ‘more than minimally’ to his death.

Mrs Marsh said Mr Shaw had been in a ‘low mood’ and a support worker had seen ‘recent visible self-harm’.

She said on the day in question the hospital allowed Mr Shaw leave to travel by taxi to a shop to buy tobacco and sent an escort with him who did not have sufficient knowledge of his complex mental health needs, which included paranoid schizophrenia further complicated by being on the autistic spectrum.

At the time, the hospital had been under Covid-19 tier four lockdown rules and no patients should have been allowed to leave the premises, but it relaxed the rules to allow Mr Shaw out.

Mrs Marsh said: “Daniel was escorted to the local shop via taxi where he had insufficient funds on his card to purchase tobacco and pay for his taxi upon return to the hospital.

“Shortly after returning from the shop, in the informal smoking shelter, Daniel stated words to the effect he was going to jump off the bridge.

“Daniel subsequently absconded from the hospital grounds and made his way on foot to the bridge.

“Despite efforts of hospital staff to de-escalate the situation, Daniel jumped from the bridge.”

Mrs Marsh said prior to absconding, Mr Shaw had not presented in any way which would have caused staff to physically restrain him, and staff who followed him to the bridge did not have any opportunity to safely stop him.

A spokesperson for Cygnet said: “We would like to express our deepest condolences to Daniel’s family and all those affected by his loss.

“We take our responsibilities to provide safe care extremely seriously and always seek to ensure any lessons learned are identified, shared, and embedded.”