Family of tragic teacher ‘shocked and disappointed’ at circumstances of his death

Graeme Mutton
Graeme Mutton

The family of popular Lincolnshire teacher who hanged himself after leaving a mental health unit say they were “shocked and dissappointed “ by the circumstances of his death.

An inquest in to the death of Graeme Mutton, from Market Deeping, found that his parents were unaware he had been allowed unescorted leave from the Peter Hodgkinson Centre in Lincoln where he was an informal inpatient.

A statement released on behalf of his family said his parents Alan and Sheila were shocked that he had been allowed unescorted leave, particularly as they had been told to ‘keep a close eye’ on Graeme during his last period of family leave.

Graeme’s body was found by police at the Greetwell Road quarry in Lincoln four days after he was allowed to leave the unit on November 24, 2015.

His family told the inquest they felt that several opportunities were missed on November 24 which may have prevented Graeme’s death, including a proper risk assessment, accurate record keeping and adequate staffing levels.

The family also felt that communication from the Trust after Graeme’s death was extremely poor.

In a statement following the inquest which concluded at Lincoln Cathedral Centre on Thursday Graeme’s family said: “Graeme was a loving and caring son, brother, father and uncle and a dedicated professional who cared passionately about education and the young people in his charge. He is sorely missed by all his family.

“Some of the questions we had about Graeme’s treatment have now been answered and although nothing can bring him back we hope that this inquest will ensure that steps are taken to minimise the risk of another family suffering the loss of a deeply loved relative in similar circumstances.”

Merry Varney, solicitor at law firm Leigh Day, represented Graeme’s family at the inquest. She said: “Having been excluded from Graeme’s care shortly before his death, his family has been shocked and disappointed to learn more about the circumstances of Graeme’s death.

“The Trust’s own investigation led to widespread recommendations for change and I welcome the recognition by the Trust that the manner in which the family were treated after Graeme’s death was also unacceptable and must not be repeated.

“Better and wider communication with families and carers, and communication between healthcare professionals is key to providing safe and effective care and treatment for people suffering mental health illness.

“To minimize the risk to future lives, we hope that the Trust will continue to ensure improvements are made to their services, especially in the areas identified by the coroner, and that changes made as a result of Graeme’s death are embedded into practice.”

In recording a narrative verdict the Coroner, Paul Smith, highlighted a number of concerns relating to a meeting between Graeme and healthcare staff on November 20 which led to him being granted unescorted leave.

The coroner said that “insufficient weight” was given to his recent presentation and historical risk status. The coroner also noted that no formal risk assessment had been undertaken in relation to granting unescorted leave.

He also found failings on the day that Graeme went missing from the hospital, November 24, in that concerns were not raised until 3pm and the Missing Person Protocol was not enacted until 8pm. However, the coroner concluded that neither of these issues contributed to Mr Mutton’s death.

Graeme was described by his family as a bright and active child who got on well with his four siblings. As a young adult he represented Scotland in hockey and played in the National League and internationally for many years.

Graeme began a career in teaching in 1997 and taught PE and Maths. He worked at Bourneville School in Birmingham from 2000 to 2014 where he was Head of Department and then Assistant Head Teacher. He later taught at Deepings School in Lincolnshire and at Thomas Deacon Academy in Peterborough.

After the inquest Dr Sue Elcock, medical director at Lincolnshire Partnership NHS Foundation Trust, said: “Our thoughts are with Mr Mutton’s family at this sad time.

“The Trust is absolutely committed to providing good quality care and following every unexpected patient death we carry out a thorough internal investigation, including a detailed action plan.

“We have made considerable change following this incident in terms of working with our staff to strengthen our risk assessment processes, ward handovers and our visible nurse and patient leave protocols. Clear and continuous communication with families has also been highlighted by this case and our Trust systems have already been changed.

“We offer our sincere condolences and apologies to the family at this very difficult time.”

THURSDAY: A coroner today (Thursday) ruled that a decision to allow a teacher limited unescorted leave from a mental health ward where he was a patient had not been properly communicated to his family or nursing staff.

Former Scottish hockey international Graeme Mutton, from Market Deeping, was last seen leaving the Peter Hodgkinson Centre in Lincoln on November 24, 2015.

The 41-year-old’s body was found four days later hanging from tree at the nearby Greetwell Road quarry in Lincoln.

Following a four day inquest Coroner Paul Smith ruled that Graeme’s family had not been present at the meeting on November 20 where a decision was made to allow him unescorted leave for one hour.

Recording a narrative verdict, the coroner said the views of Mr Mutton’s family had not been canvassed and insufficient weight had been given to Graeme’s recent history and risk.

The coroner said insufficient consideration was also given to the withdrawl of Graeme’s family support by the centre and his fear that he would not be allowed to live with his mother on discharge.

The decision to restrict Graeme’s unescorted leave to one hour was also not passed on to nursing staff, and his departure from the ward on November 24 was not recorded in the visible ward log, the Coroner ruled.

An incorrect note recording Graeme’s return to the ward was also made and the unit’s missing person protocol was not implemented to nearly ten hours after he went missing.

But the coroner concluded by saying that it was not possible to say if these matters had any connection to his death.

The inquest at Lincoln Cathedral Centre heard Graeme suffered from depression and at the time of his death was an informal inpatient at the Peter Hodgkinson Centre and going through a divorce.

He was born in Lanark and represented Scotland at under 18, under 21 and the full national side as a hockey goalkeeper.

During the inquest Graeme’s family expressed their shock that he had been allowed unescorted leave from the unit and asked the coroner to consider that decision and how he presented in the immediate days before he went missing.

Lincolnshire Partnership NHS Foundation Trust has acknowledged to Graeme’s family that communication regarding his unescorted leave was not as it should have been and that once he went missing the incident could have been escalated earlier.

But the inquest heard it was the view of Graeme’s family that there was not enough evidence to know if an earlier realisation that he had gone missing could have made a difference.

After recording his verdict, the coroner said he had yet to decide if he would make any formal recommendations following the inquest.

Graeme was a maths teacher at the Thomas Deacon School in Peterborough and had also worked at the Deepings School and in Birmingham.

The former Stamford School pupil had a teenage son and also played football and rugby locally.

In a statement which he read to the inquest, Graeme’s father, Hedley Alan Mutton, said his son had three sisters and one brother and came from a close family who supported him throughout his illness.

The inquest heard Graeme separated from the mother of his son in 2008 and was first referred to mental health services in that year. He married a new partner in 2012 but that relationship broke down in 2014.

Mr Mutton said Graeme rose to the rank of deputy head at the Bournville School in Birmingham but lost his job when it became an Academy in 2014. He returned to Lincolnshire where he lived with his mother, Sheila.

The family became concerned when Graeme was found lying on his bed with a belt around his neck in August 2015, and he was voluntarily admitted to the Peter Hodgkinson Centre where they visited him every day.

Mr Mutton said in November 2015 the family were told to “stay away” from visiting Graeme as he had become too dependent on them.

Graeme was allowed two days home leave at his mother’s on November 20 which his father described as “very difficult.”

Mr Mutton said: “He admitted to me he had dark thoughts. I remember Sheila saying he did not have enough medication to stay at home. As we left he ran back in to the house twice to say goodbye to the family.”

The inquest heard Graeme sent a text to his mother on November 23 in which he said there was an 18 month waiting list for therapy. On the same day Graeme also told a nurse he was worried about his future.

Graeme’s mother received a call at 5.45pm on November 24 and was told he had been missing for two hours, the inquest was told.

“We were shocked Graeme was missing and very upset,” Mr Mutton said.

“We were originally told he left at 3.45pm, later that he left the ward at midday, now we know it was much earlier.”

CCTV showed Graeme leaving the ward at 10.18am and the building two minutes later. Further CCTV at 10.38am showed Graeme buying rope from a store near to the quarry where he was found.

The inquest heard Graeme was noticed missing at 1pm but no concerns were raised and his phone went unanswered during mid afternoon. His phone was later found under his bed.

Mr Mutton said although Graeme was not found until November 28, his family believed he took the steps to end his life on November 24.

TUESDAY: A teacher told a nurse he was “worried about his future” a day before he went missing from a mental health unit in Lincoln, an inquest heard today (Tuesday).

Graeme Mutton (41) was found hanging from a tree in a disused quarry four days after he walked out of the Peter Hodgkinson Centre in Lincoln where he was an inpatient.

An inquest at Lincoln Cathedral Centre heard Graeme, from Market Deeping, suffered from depression and was going through a divorce at the time of his death in November 2015.

The inquest was told Graeme walked out of the unit at 10.20am on November 24 and a short time later was seen on CCTV buying rope from a nearby Go Outdoors store. His body was found in the Greetwell Road quarry on November 28.

Giving evidence to the inquest, a mental health nurse who worked on the ward where Graeme was staying, said she spent 20 minutes talking with him on November 23 after he approached her and asked for a one to one conversation.

The nurse said: “He was saying to me he was worried about his future.”

Graeme was advised to break his problems down. The nurse added: “He said he had done that previously and it had been helpful.”

The nurse said she later saw Graeme speaking on the phone and laughing, and told the inquest she had no concerns for him at that time.

When asked by the Coroner Paul Smith what she understood to be Graeme’s leave and escort status, the nurse replied: “Unescorted.”

The inquest previously heard that Graeme’s family were shocked to learn that he had been allowed unescorted leave from the hospital.

Graeme was a maths teacher at the Thomas Deacon school in Peterborough and had also worked at the Deepings School and in Birmingham.

He was a former Stamford School pupil and represented Scotland in hockey at full international level.

The inquest, which is expected to last five days, continues.

MONDAY: An inquest has today (Monday) opened in to the death of a popular school teacher from South Lincolnshire. Hedley Graeme Mutton, known as Graeme, was last seen leaving the Peter Hodgkinson mental health centre in Lincoln on November 24, 2015.

The 41-year-old’s body was found four days later hanging from a tree at the nearby Greetwell Road quarry in Lincoln.

Graeme, from Market Deeping, was a maths teacher at the Thomas Deacon school in Peterborough and had also worked at the Deepings School and in Birmingham.

The former Stamford School pupil had a teenage son and was a talented international sportsman who represented Scotland at hockey and also played football and rugby locally.

An inquest at Lincoln Cathedral Centre was told Graeme suffered from severe depression and was an inpatient at the Peter Hodgkinson Centre. He was also going through a divorce at the time of his death.

In a statement which he read to the inquest, Graeme’s father, Hedley Alan Mutton, said his son had three sisters and one brother and came from a close family who supported him throughout his illness.

The inquest heard Graeme separated from the mother of his son in 2008 and was first referred to mental health services in that year. He married a new partner in 2011 but that relationship broke down in 2014.

Mr Mutton said Graeme rose to the rank of deputy head at the Bournville School in Birmingham but lost his job when it became an Academy in 2014. He returned to Lincolnshire where he lived with his mother, Sheila.

The family became concerned when Graeme was found lying on his bed with a belt around his neck in August 2015, and he was voluntarily admitted to the Peter Hodgkinson Centre where they visited him every day.

Mr Mutton said his son “wept uncontrollably” when his consultant told him she was leaving in October 2015, and a month later the family were told by a locum consultant that there was a new diagnosis of a personality disorder.

They were also told to “stay away” from visiting Graeme as he had become too dependent on them, Mr Mutton told the inquest.

Mr Mutton said Graeme was also worried that he would not be able to stay at his mother’s. “There was no basis for this at all,” Mr Mutton said. “Graeme was always welcome and accommodated by his family.”

The inquest heard Graeme was allowed two days home leave at his mother’s on November 20 which his father described as “very difficult”.

Mr Mutton said: “He admitted to me he had dark thoughts. I remember Sheila saying he did not have enough medication to stay at home. As we left he ran back in to the house twice to say goodbye to the family.”

The inquest was told Graeme sent a text to his mother on November 23 in which he said there was an 18 month waiting list for therapy. The next day calls to Graeme from his family were not answered.

Mr Mutton said Sheila received a call at 5.45pm on November 24 and was told Graeme had been missing for two hours.

“We were shocked Graeme was missing and very upset,” Mr Mutton said.

“We were originally told he left at 3.45pm, later that he left the ward at midday, now we know it was much earlier.”

The inquest heard CCTV showed Graeme leaving the ward at 10.18am and the building two minutes later. Further CCTV at 10.38am showed Graeme buying rope from a nearby stored.

Mr Mutton said although Graeme was not found until November 28, his family believed he took the steps to end his life on November 24 and that there were a number of missed opportunities on that day to prevent it.

They included adequate risk assessments, accurate and recorded time keeping and adequate staffing levels.

“We were shocked to learn Graeme had been allowed unescorted leave from the hospital,” Mr Mutton said.

Mr Mutton added that if it is was found that Graeme’s death was preventable then it might reduce the risk of other families suffering in similar circumstances.

The inquest, which is expected to last five days, continues.