Jury concludes that a serious failing by an NHS Trust led to the death of AZ, a mental health in-patient; Frederick Powell acted on behalf of the Family
AZ was admitted to an acute mental health ward of St Peter’s Hospital on 8 May 2020. He presented with low mood, suicidal thoughts, depression, exhaustion, and had a recent history of self-harm. A few hours previously, he had been assessed as “high risk” by a Psychiatric Liaison Team at a different hospital, following concerns raised by his family.
AZ arrived at St Peter’s Hospital with two bags. On admission to the St Peter’s Hospital, neither AZ nor his bags were searched. Medical and healthcare staff considered that AZ’s risk to himself should be downgraded to medium.
At about 1pm on 9 May 2020 (about 36 hours after admission), AZ was found hanging from a ligature fashioned from two conjoined shoelaces in his dormitory bathroom.
The Jury found that there was a “serious failing” by the Trust to identify and remove the hinge to the dormitory bathroom posed a “significant risk” to patients. The Jury also found that the failure to perform an adequate search of AZ and his belongings “represented a missed opportunity to identify potential ligatures in his possession and to engage with AZ in the process.” Furthermore, the Jury found that the assessment of AZ’s welfare needs and the formulation of his care plans was “inadequate”, and that the supportive observations were carried out with “inadequate engagement, recording and reporting”.