Jury find that 14 causative failings and neglect by NHS Trust led to the death of Phil Lamplough, a mental health in-patient who took his own life

Philip Lamplough, known as ‘Phil’, died on 17th April 2020 at St Peter's Hospital, Surrey. He was 53 years old and had been a mental health in-patient at the Abraham Cowley Unit (ACU), part of Surrey and Borders Partnership NHS Trust, between 13th – 15th April 2020. Phil died of a hypoxic brain injury caused by asphyxiation by hanging, following an attempt to take his own life on 15th April 2020.


Phil experienced a significant decline in his mental health at the start of lockdown in April 2020. He attended East Surrey Hospital on the 3rd April after taking an overdose of prescribed medication in an attempt to end his life, and Royal Surrey County Hospital on 11th April after contacting 111 due to suicidal thoughts. On both occasions, he was discharged by psychiatric liaison. After being discharged on 11th April, Phil returned to his temporary accommodation and self-harmed by cutting his leg.

On the morning of the 12th April, Phil was evicted from his accommodation due to the self-harm and was taken by the police to a homeless shelter. Staff later called the emergency services as Phil was attempting to walk into traffic. Phil was detained by the police under s.136 Mental Health Act (MHA) and taken to a place of safety. He was assessed under the MHA and found to be apparently psychotic (paranoid and hearing voices) and suicidal. It was decided Phil should be detained under s.2 MHA for a period of further assessment.

Admission to ACU

Phil was admitted to Clare Ward of the ACU on 13th April 2020. Due to his suicide risk, he was placed under 15-minute observations. On admission, Phil decided to stop taking his regular prescription of methadone (a heroin substitute), which would have led to serious withdrawal symptoms. Unfortunately, there then followed a series of failures in his care and management, as set out below.

On 15th April 2020, members of staff found Phil in a toilet cubicle, where he had managed to hang himself by attaching his hoodie cord to a wooden doorstop (part of the cubicle door frame). He was taken to St. Peter’s hospital, where he died a few days later.

Expert opinion  

The expert psychiatrist instructed by the Coroner considered that Phil had an independent mental health problem, and was suffering a relapse of psychotic symptoms. His decision to kill himself was an impulsive one which was probably caused by: (1) ongoing psychotic symptoms, particularly paranoia; and / or (2) methadone withdrawal symptoms. Phil would also likely have felt a sense of despair that no-one was helping him or attending to his needs.

Jury Conclusion

After nine days of evidence, the jury concluded that Phil died of suicide and his death was contributed to by neglect. The jury found that the following failings all probably made a material contribution to his death:

  1. Failure to undertake a specific risk assessment and create a treatment plan to deal to the risk of methadone withdrawal and the need to monitor for withdrawal symptoms.

  2. Failure to assess Phil for methadone withdrawal using an opiate withdrawal scale 4 times a day to monitor for withdrawal signs.

  3. Failure to ensure that the SBARS (shift handover documentation) contained specific reference to the need to observe Phil for methadone withdrawal.

  4. Failure to follow the observation policy and record adequate information in the observation log in relation to methadone withdrawal.

  5. Failure to act expeditiously or effectively when Phil repeatedly sought a review of his medication in general and in particular on the 15th April 2020 when he asked for Subutex.

  6. A lack of staff training about methadone withdrawal and dual diagnosis patients.

  7. Failure to undertake an adequate risk assessment and record a care plan to assess and manage Phil’s psychotic symptoms after the ward round on the 14th April 2020.

  8. Failure to ensure that the SBARs made specific reference to the need to observe Phil for psychotic symptoms.

  9. Failure to follow the observation policy and record adequate information in the observation log in relation to psychotic symptoms.

  10. Failure to escalate the psychotic presentation observed by staff on the 15th April 2020.

  11. Failure to engage sufficiently with Phil on a one-to-one basis to ensure that his needs were met and he felt reassured that his mental health and withdrawal symptoms would be addressed.

  12. A lack of staff training around the taking and recording of observations.

  13. A lack of time available to carry out observations.

  14. The unintentional creation of a ligature point by the cutting down of the toilet cubicle door stop in 2018.

In addition, the jury found that the following failings all possibly made a material contribution to Phil’s death:

  1. Failure to take advice from i-access Drug & Alcohol Service as a matter of urgency when Phil refused to continue to take methadone on admission to ACU.

  2. Failure to provide Phil with adequate mental health support by psychiatric liaison on either, or both, of the 3rd April 2020 or the 11th April 2020.

  3. Failure to provide adequate staffing on the ward to meet Phil’s needs.

The family was represented by Matthew Turner instructed by Elaine Macdonald and Lucinda Hawthorn of Tuckers Solicitors.

The Coroner was HM Assistant Coroner for Surrey, Caroline Topping. 

The other Interested Persons were Surrey and Borders Partnership Trust, Surrey County Council, and South East Coast Ambulance Service.