“Evidence was given by staff members of the East London Foundation NHS Trust that: 1”

The coroner’s concerns

Evidence was given by staff members of the East London Foundation NHS Trust that: 1. The deceased was allowed to leave Gardener Ward (“the unit”) which was part of a secure facility of the hospital, alone, when a clinical decision had been taken that they should not be allowed to leave the unit unaccompanied by staff, because they posed a serious risk of suicide. 2. The decision that the deceased should not be allowed unescorted leave was not communicated to all members of staff working in the unit such that the person who allowed the deceased to leave was unaware that the decision had been made. 3. The relevant information gathered during the Ward Round on the 28th October 2021, which included the fact that the deceased had attempted to take their own life, the night before, was not adequately communicated to all staff on the unit. 4. The “Sign in/Sign out” book which was supposed to record the movements of service users in the unit was frequently not completed, particularly when service users went out for short periods. 5. There was no proper system for identifying whether a service user 4 should be permitted to leave the unit. 6. The member of staff who allowed the deceased to leave the unit made a brief risk assessment of them before deciding whether they should be allowed to leave. That person did not consult any medical notes or records about the deceased when making that assessment. Had that member of staff consulted the deceased’s medical notes and records, the serious suicide risk which they posed would have been evident. 7. Once the deceased was found to be missing from the unit, there was an unexplained delay in informing the police and ambulance service, a failure to inform either of the serious suicide risk which the deceased posed to themselves and a lack of appreciation of the urgency of the situation by staff generally. 8. The hospital policy which applied to missing patients was not properly adhered to by staff and there was confusion about who should be contacted and in what manner, once a patient was found to be missing. 9. No proper efforts were made to contact members of the deceased’s family once the deceased was found to be missing. 10. The unit was short-staffed and this affected the care provided to the deceased, the assessment of the deceased whilst in the unit and record keeping generally. The summary of the evidence given, as set out above, sets out the matters of concern.

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, 2023-0198

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