Teenager found dead after leaving mental health hospital for a cigarette break, inquest is told

Keaton Shawn Burton, 19, was a voluntary inpatient with Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust when he was found in woodland off Toll Bar Road in Ryhope on June 24, 2019.

An inquest at Sunderland Coroner’s Court heard Keaton had been staying at the trust’s Fellside Ward unit in Newcastle after an attempt to self-harm.

The hearing was told records of Keaton’s treatment has been reviewed by consultant psychiatrist Dr Catarina Gois.

As a voluntary patient, staff had no power to detain him and he had been allowed short periods of unescorted leave, which he had mainly used for cigarette breaks in the grounds.

Assistant coroner Karin Welsh asked Dr Gois whether Keaton’s agreed care plan was sufficiently clear on leaving the ward. Dr Gois replied: “I felt there were some difficulties with clarity. It should be recorded in a more detailed manner.”

The inquest also heard a review which should have been carried out with 72 hours of Keaton’s admission had not been done and a ‘Getting to Know You ‘ report, which would have allowed his family to raise concerns about his ongoing paranoid mental state had not been completed.

READ MORE: Inquest into death of Sunderland teenager Keaton Burton will hear about mental health trust's care during hearing

After Keaton expressed a desire to go out late on June 20 with his friends, it had been decided to sit down with him and agree exactly what was acceptable with regard to leaving the ward, but Dr Gois said there was no record of such a meeting taking place.

Asked if an updated care plan had been produced to clarify the rules, she said: “As far as I can find in the records, I don’t think there was.”

On June 23, Keaton had asked to go out at around 10.30pm for a cigarette break. He never returned.

Asked whether he should have been sectioned, Dr Gois said she would not have done so: “He was sleeping better, he was eating. He had identified a number of positive things and he was talking about wanting to change his life, to start over,” she said.

"Looking at all that information we had at the time, I think I would not have made a decision to detain him.”

The inquest continues.