We represented the family of a vulnerable man who tragically died while detained under Section 2 of the Mental Health Act at a hospital run by South London and Maudsley NHS Foundation Trust (SLaM). He had presented to A&E following a significant self-inflicted injury, triggered by hearing distressing voices in his head. Despite being detained under section for two weeks, he remained distressed, and reported to staff on the day of his death that the voices were just as intense as when he was first admitted.

However, the hospital failed to carry out appropriate risk assessments or put in place an adequate care plan. There was not a single person on the ward that he knew well or who had built a therapeutic relationship with him. As a result, no single staff member developed meaningful insight into his risk profile. Tragically, he took his own life in his hospital room after staff did not carry out an hourly observation on time.

Critical findings

We worked with the family to prepare for the inquest, reviewing evidence and identifying key failings in the care provided. We raised these concerns with the Coroner to ensure they were fully explored during the final inquest hearing.

Conclusion

At the inquest, the jury returned a highly critical narrative conclusion. They identified multiple failings by SLaM, including:

• the failure to document that the deceased had reported experiencing symptoms with the same intensity as when he was first admitted,
• inadequate risk assessments and observations on the day of his death,
• and a lack of meaningful engagement with his primary nurse.

They concluded that these failings amounted to a lack of proper monitoring on the ward, which contributed to his death.

The family was represented by solicitors, Keiu Kikas and Mollie Eglesfield, with support from paralegal Felix Parsons. Fatima Jichi of Garden Court Chambers was instructed as Counsel.