Inquest finds multiple police and hospital failings caused death of psychiatric patient

11.11.14 | |

Melina Padron acted for the bereaved family in a 2-week inquest touching on the death of an informal psychiatric patient with a history of depression, alcohol dependence and suicidal ideation. Having been detained by Surrey Police under section 136 of the Mental Health Act 1983, he subsequently agreed to be admitted to Epsom General Hospital as an informal patient. He went on unescorted leave and failed to return to hospital. This was reported to Surrey Police by nursing staff, who provided information about his risk to self and noted he had visited the website of a chain of hotels, one of which is located across the road from the hospital.  The patient was ultimately categorised as absent and no further police enquiries were made. The patient was found dead the next morning at the hotel opposite the hospital.


The jury concluded that the patient had taken his own life and made critical narrative factual findings regarding failures in the police investigation, lack of training of police and hospital staff in mental health risk assessment and missing persons policies, failures of communication between agencies and failures by agencies to make further enquiries. The Coroner ruled that he would be making Prevention of Future Deaths reports to both the hospital and Surrey Police in respect of training, communication and policy gaps highlighted in evidence.


In the inquest, Melina Padron was instructed by Yasmin Husain of McMillan Williams.

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