“On completion of the inquest, I found the decision to rescind detention under s.2 on…”

The coroner’s concerns

– 1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects: a) A failure to update a suicide self-harm risk assessment. b) A failure to formulate a Care and Treatment plan identifying core treatment needs. 2 A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment element and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that this risk to life has been satisfactorily reduced. However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up. The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness. As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs. The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs. The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use. I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recission of s.2 was correct. The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation. My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019. The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue. Accordingly, I am reporting this matter to the Minister for Health and CNWL Trust to make such recommendations as they see fit arising from the expert evidence uncovered by the inquest so that any necessary lessons can be learned. 2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight. i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life. ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII. 3 iii) A nurse who called the police, sometime before 00:30 according to the medical records, or at 01:10 according to police records, was not interviewed by the SII. I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion. The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2. I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others. I therefore wish to report this matter to the Minister for Health and CNWL Trust to make such recommendations as they see fit including the adequacy of the SII investigation.

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, 2022-0330

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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