“5 1”

The coroner’s concerns

– 5 1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden. 2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0533

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0