By Michael Holmes
You can read this article on The Lead here

Staff at a £1,149-a-night private hospital in Altrincham failed to refer a mentally ill headteacher to the NHS when he was discharged - just six days before he killed himself.

If workers at the Priory Hospital in Rappax Road had referred Benjamin Sulzbacher to the national health service’s home-based treatment team, it would have seen him face-to-face within 72 hours and, if needed, kept in touch with him for up to four weeks, an inquest was told.

But there was confusion around what help the rabbi could get on the NHS - and he was left to suffer a relapse and die from suicide in Philips Park, where he was reportedly found dead by a long-time friend.

Manchester North’s senior coroner Joanne Kearsley has now written to health bosses warning of more deaths unless something is done.

She told Priory boss Rebekah Cresswell, Health Secretary Victoria Atkins and Mark Fisher, chief executive of the NHS Greater Manchester Integrated Care Board: “I believe each of you respectively have the power to take such action.”

Father-of-eight Sulzbacher, 48, who had worked as the head of Manchester Mesivta School, was described at the inquest into his death as a “pillar of the community”.

He was taken to A&E at North Manchester General Hospital last August after he “tried to tie a ligature at home”, Kearsley said.

He was assessed and found to be in need of admission, which he agreed to, but the only available acute inpatient bed was in the south, so his family paid for a private admission at the Priory, where he stayed from August 26 to September 18.

Medics at the Priory, which was judged to be ‘good’ after its last routine inspection by the health industry regulator Care Quality Commission (CQC) in 2019, were meant to carry out a follow-up phone call within 48 hours of discharge, Kearsley said. 

But the call only happened on September 21, three days later, with Kearsley saying “learning from how this call was conducted has already been recognised by the Priory”.

And she said: “The court heard evidence that no referral was made to the NHS mental health trust for a follow up via the home-based treatment team.”Kearsley added: “This would have occurred automatically if he had been an NHS inpatient.

“The court also heard evidence that the NHS trust would have accepted such a referral even though Sulzbacher had been a private-paying inpatient.”

Action to prevent more deaths

Addressing Priory chief executive Cresswell, the coroner wrote in her regulation 28 report, sent when action is needed to prevent more deaths: “There was a lack of understanding from the Priory witnesses as to what the NHS community services could offer on discharge. The court heard that the home-based treatment team was understood to simply be a ‘crisis team’, which was incorrect.”

And to Atkins and Fisher, Kearsley said: “It was unclear to all services as to whether a private-paying inpatient - who would have qualified for care under the NHS but due to bed availability went private - would be entitled to be referred to the discharge services offered by the NHS.

“The NHS provides more than the private sector in respect of community discharge packages and can be engaged with someone for longer. 

“Importantly, the face-to-face contact enables a better understanding of how a patient is actually presenting when considering their mental health.”

The NHS Greater Manchester Integrated Care Board said it would not answer The Altrincham & Sale Lead’s questions until it has responded to the coroner, who has given a deadline of July 12.

The Altrincham & Sale Lead also asked the Department of Health and Social Care a number of questions; a spokesperson declined to comment because they said doing so would breach pre-election period guidance.

Speaking at the inquest, Sulzbacher’s son-in-law Alex Whittler said: “He was an incredible role model and loved by everyone. He was an extremely special person - very genuine and real.”

Sulzbacher began to experience anxiety and depression in February 2021, the inquest was told, according to the Bury Times.

In the months before his hospital admission he was “struggling” because of stress at work and feared losing his job.

Last August, Sulzbacher threatened to kill himself and was seen with rope, which he put in the back of his car, the court was told.

An ambulance was called and he was later admitted to the Priory.

Sulzbacher’s loved ones are said to have voiced their concerns after he was found with another ligature at the hospital three days after his arrival and after they were told he would be eligible for a two-day trip home from September 8-10.

Whittler said: “This was 10 days after being admitted, being actively suicidal. We couldn’t get our heads around it.”

When Sulzbacher was discharged on September 19, his family was not told and he arrived home in a taxi, the inquest was told.

“We didn’t see any discharge papers,” Whittler said. “There were no plans in place.”

"Robust protocal"

A spokesperson for the Priory, which says on its website it offers “specialist mental health treatment that can put you on a path to a positive, fulfilling future”, told The Altrincham & Sale Lead: “Patients and families are always involved in choices about discharge arrangements and aftercare. 

“Priory has a robust protocol in place re post-discharge management and patients who do not have a follow-up appointment scheduled with an NHS service receive a call within 48 hours of discharge which is the process followed with Sulzbacher.

“Where patients indicate that they want to re-engage with NHS services, referral letters need to be sent not only to GPs (as is standard practice) but also to NHS community treatment teams so they can follow up directly with the patient within the expected 72 hours and this will be reinforced across Priory following the coroner’s report. 

“Where a patient does not require further NHS input, we continue to ensure a follow-up call is made by Priory within 48 hours in accordance with current practice.”