“that remain, are as follows”

The coroner’s concerns

that remain, are as follows. 1. I heard that, following Mr White’s death, the level of (mental health) observations of a patient at the Whittington Hospital Emergency Unit is now clearly documented. However, I am not sure that there is yet a robust protocol in place to ensure that all relevant personnel (Whittington EU doctors, nurses and security officers; also visiting independent s12 doctors, BEH and C&I staff) are aware of the level. 2 My concern arises because sometimes, when anyone can look at a record, that nobody actually does. 2. The C&I approved mental health professional (AMHP) who gave Mr White permission to leave the hospital to go to McDonald’s, after the decision had been made to detain him under section 2 of the Mental Health Act, acknowledged that she should have discussed this first with a colleague. However, she remained of the view at inquest that the decision itself had been the right one. Proof of this, she explained, was the fact that Mr White did return to the hospital from this visit. Allowing leave in these circumstances was a very unusual step I am concerned at the lack of recognition, even so long after the event, that allowing a person to leave the hospital in these circumstances: - was not necessarily the right one simply because the patient returned on this occasion (he left again within half an hour and never returned); and - had the potential to lull others into a false sense of security about his risk of absconding. The trust’s root cause analysis action plan merely describes the need to have legally authorised permission to leave, without addressing any question of how to shape clinical decision making.

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, 2017-0177

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