A jury found issues with hospital staff actions after Jordan Kelwick died near Bude in July 2023.
A jury investigated his death and found issues with the actions of hospital staff. Jordan had been in Bodmin Hospital, specifically Fletcher Ward, a psychiatric unit, since May 7, 2023, where he was treated for treatment-resistant schizophrenia.
Jordan left the hospital at 1:25 pm with unescorted leave, scheduled to return at 1:55 pm. He went to a nearby garage and called a taxi at 1:54 pm, which took him near Bude.
Staff called 999 at 2:50 pm to report him missing, 55 minutes after he was due back. They had searched the hospital grounds but couldn’t find him.
After the taxi ride, Jordan called his stepfather, stating he felt low and that the voices he heard were worse. He subsequently fell from the cliff, sustaining many injuries, and a medic pronounced him dead at 4:44 pm.
The jury determined Jordan intentionally fell, highlighting shortcomings in granting him leave and noting a lack of family involvement, which may have contributed to his death. They also noted staff didn’t realize he was missing quickly. The jury stated the lack of a responsible person for leave was unacceptable, issues it found contributed to his death.
The jury also noted procedures were not followed and contact with family was inadequate, factors that may have affected Jordan’s outcome.
Jordan’s stepfather described him as kind and lovable, with a great sense of humor. Jordan moved to Bournemouth at 19 but his mental health declined suddenly, leading him to request a return to Cornwall in 2020.
He said he had changed his name to Gary Gary and talked about spirits. The family had no contact after May 2023. They didn’t know about the leave request and would have opposed it, believing Jordan misled the staff about his feelings.
The ward manager stated Jordan appeared improved and less distressed before the leave, having opened up to the staff. He believed the leave was therapeutic, providing fresh air, even though the staff knew Jordan didn’t want info shared.
The manager added that while family could have provided useful information, it might not have changed anything. A psychiatrist suggested family information might have delayed the leave, but staff ultimately make the decisions. He said he had seen Jordan relaxed before his leave and thought it possible finding him sooner was possible, but no one checked for his return.