22nd January 2016

Adam Withers was just 20 when he fell to his death from a 130ft industrial chimney in the grounds of Epsom Hospital, on 9 May 2014.  He had been diagnosed as suffering from an acute psychotic illness and had told staff that day that he wished to climb a ladder that had been recently fixed to the side of the chimney.  There was a history of patients on the ward absconding by climbing over the roof of the ward beside the chimney, and Adam himself had previously done so.  In spite of that documented history, nothing had been done to make the ward safe, and no additional steps were put in place to protect Adam on the day of his death.  The site of the chimney was also left unsecured and the ladder was easily accessible.  

The inquest jury has heard disquieting evidence about the standard of care on Elgar Ward.  This was characterised by poor record-keeping, a lack of risk assessments and care planning, and the almost complete absence of effective communication between nursing staff in the lead up to Adam’s death.  

The Withers family is grateful to the jury for their careful consideration of the evidence and for reaching a conclusion which very much mirrors the concerns they have held since Adam’s death.

Adam’s mother, Michelle Withers, who is also a Registered Nurse said:

We believed that Adam was in a place of safety and learning instead that his death should and could have been avoided has made his loss all the more distressing.  Whatever changes have been introduced since, these will only ever be as good as the people on the ground whose job it is to care for people like Adam.”

Carolynn Gallwey, family solicitor said:

"This was an avoidable death and demonstrates the importance of proper resourcing and high quality nursing in psychiatric care.

Deborah Coles, Director of INQUEST said:

"This tragic death once again points to under resourced and overstretched mental health services that are failing vulnerable people. This case must prompt an urgent review of action that needs to be taken to stop this happening again both at a local and national level."


INQUEST has been working with the family since May 2014.  Family is represented by INQUEST lawyers Group member  Carolynn Gallwey of  Bhatt Murphy Solicitors and barrister Chris Walker from Old Square Chambers.