“, ~- Mr Ajayi was aged 45 when he died, He had a long history of mental iliness and a…”

The coroner’s concerns

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, ~- Mr Ajayi was aged 45 when he died, He had a long history of mental iliness and a forensic history. He suffered with severe mental iliness with a diagnosis of paranoid schizophrenia In 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had litle or no contact with his familly in the time leading up to his death. In the last hospital admission before his death he was diagnosed with HONK — Hyperosmolar non-Ketotic coma, This means his blood sugar was high. He now required Insulin to contro! his diabetes and he was, when discharged, to administer this to himself twice a day. On the 9" August 2042 there was a discharge planning meeting at the Maudsley (his last hospital admission), His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order In place. His named Care Coordinator does not seem fo recall much about this meeting but has acknowledged that he would have been fold that Mr Ajayi was now insulin dependent, From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabatic nurse aware of his discharge. Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that milltated, practically, in relation to them visiting post discharge. No one was to visit him. Te use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility, The job must be carried out with great diligence and care, Staff must be of the right calibre, and have the right training, and support, to carry out thelr tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society. it cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to administer life-saving treatment fo themselves. Therefore, they are particularly vulnerable. | acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have thelr risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators, I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an Individual such as Mr Ajayl (who was on the Sexual Offender's list as well as having the problems clted above), is, and was, limited. However, this report Is not concerning that issue, It cancers the ability of this group of staff to carry out their jobs ensuring the lowest poselble risk to thelr users as can he achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing, | am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multl-disciplinary approach including monitoring of 7 day follow up and | am told Is robustly monitored in respect of compliance with the seven day follow up), and the Identification of high risk patients such as Mr Ajayi. 1 am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, | did not find this evidence reflected in the Care Coordinators’ evidence. | have not been shown any audit figures to prove that changes have been checked as in actlon comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-tralning was evident. Both Care Coordinators were experienced and both also knew Mr Ajayl and his history, albeit not acting upon his new diagnosis, The evidence as a whole came across as still a sorvice dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual’s well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory contro! over some users of the service, at that particular time. | have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, | am struggling to find any other tangible changes that | am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.

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, 2014-0558

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