Coroner concludes that NHS Trust’s failings led to the death of TH, a mental health patient who absconded from A&E

TH self-presented at the Accident and Emergency Department at William Harvey Hospital in the early hours of 7 December 2020 in the middle of a psychotic episode.  On assessment, he repeatedly demanded admission to a nearby hospital and verbalised a wish to leave A&E.

Clinical staff universally determined that TH was a “high risk” patient on account of his suicide and absconding risk. It was decided that he should be placed on continual 1:1 observations.  This was never arranged.

After about three hours of waiting in the A&E waiting area, TH left the Hospital. None of the staff witnessed him leaving and his absence was only noticed about 30 minutes after his departure. 

Shortly afterwards, TH was hit by a heavy goods vehicle on a major road nearby the Hospital. It was reported that TH was acting strangely and wandering into traffic.  TH was taken by ambulance to Kings College Hospital in London with life-threatening injuries from which he tragically died on 13 December 2020.

The Coroner found that clinical staff at the Hospital failed to monitor TH appropriately whilst he was in A&E, and that there was a missed opportunity to assess and treat his mental ill-health.  She found that these clinical errors caused TH’s death.   She also found that there were failings of the community mental health team to assess TH. 

Frederick Powell, instructed by Kim Vernal of Taylor Rose MW acted for TH’s parents.  Frederick specialises in healthcare-related inquests and human rights law.