Open verdict on former editor killed by train

Dear Sir

Thank you for running the story 'Open verdict on former editor killed by train'. We are concerned that readers were left with the impression that DON SMITH died after an "unsuccessful weekend visit to his home".

We have in our keeping a heavily censored investigative report into the collapse of care at Edenbrook hospital, Stevenage, that occurred during Don's second stay there (April 20 - July 1).

The 'Root Cause Analysis Report into Serious Adverse Event' points to more than 20 management, training and personnel failures that are directly related to Don's death. This included an admission that the critical role of "Primary Named Nurse" failed because the nurse didn't know this was his role.

After several meetings with the NHS Partnership team that authored the report, it comes as no surprise to us that no one spotted the seriousness of his downturn after the drug Olanzapine (strong anti-psychotic/tranquiliser) was discontinued.

The really sad fact is, that this was the same downturn that had led to his readmittance to the hospital just two months earlier but no one at Edenbrook spotted it. Even the psychologist who met with Don 2 days before his death failed to report that Don told him he "saw no future" and, that same day, Don was even given Temazepam the drug that drove him into care.

We believe the Olanzapine masked Benzodiazepine withdrawal symptoms and side-effects that had brought Don to his knees. After 10years of poorly managed Temazepam (Benzodiazepine) prescribing, Don had unwittingly become addicted to the drug.

Unfortunately Don was treated for depression rather than the anxieties and symptoms presented by withdrawal from Benzodiazepines.

We've made repeated requests for the release of the uncensored report but have been denied on the grounds that it relates to key members of staff and a second assumed suicide. (If any of your readers know the identity of the second person we'd really like to hear from them, as together we might stand a better chance of understanding our loss).

Fortunately, Don, forever the meticulous journalist, kept his own record of the 10 years of SSRi/Benzodiapine prescriptions that lead to his admittance to Edenbrook, and we are only too aware as to what happened thereafter.

The "unsuccessful weekend" was just one step in a spiralling journey of anxiety that could and should have been avoided. It pains us to think anyone might think otherwise.

Yours sincerely

Sylvia, Robin, Nick, Marcia & Dryden Smith