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Death fall inquest lists hospital lapses

Whittington increases staffing after jury pinpoints poor communication and lack of support

26 May, 2017 — By Koos Couvée

Patient Dominic White

“INSUFFICIENT communication” between staff and “lack of support” for his family contributed to a psychotic man absconding from Whittington Hospital before he died after throwing himself off a building, an inquest jury has concluded.

In a damning verdict, the jury at St Pancras Coroner’s Court identified a series of failings by mental health services over the care of Dominic White, 27, who was found dead at an electricity substation in Stock Orchard Crescent, Holloway, on November 10 last year.

The father-of-one had been sectioned under the Mental Health Act but ran away from the Archway hospital while waiting to be transferred to a privately-run secure mental hospital in Stevenage, the day before his body was found.

In a narrative conclusion given last Friday, jurors criticised the fact that Mr White spent six hours in a cubicle at A&E that was “bad smelling, dingy and with no natural light or ventilation”, adding: “He was offered no food or water”.

The inquest heard that in a highly unusual move sanctioned by a mental health nurse, Mr White was allowed to go out with his mother Lynne to get some fresh air and food at McDonald’s – despite the fact he had been sectioned under the Mental Health Act.

The jury pointed out that this surprised a doctor, a security guard and the nurse in charge of A&E, and “decreased the perception of various parties to the risk of Dominic absconding”.

Mr White and his mother returned 20 minutes later but he absconded around half an hour later. In dramatic CCTV footage shown to the jury, Mr White’s mother Lynne was seen desperately trying to stop her son running away, before he broke free from her grasp and ran down Highgate Hill.

The jury said Mr White was deemed low risk. Hospital staff agreed with security guards that he could be monitored by CCTV from their office. But following a handover, the court heard, guards were occupied with other duties and did not see him leaving.

Due to staff shortages, there was no nurse available to monitor Mr White.

“The above, the insufficient communication between parties and lack of support for Dominic’s family escalated and contributed to this serious incident,” the jury found.

Mr White had been taken to hospital from his home in Crouch End after his increasingly erratic and at times aggressive behaviour alarmed his family. He said he could see demons and at one point tried to climb out of a front-room window.

Two days earlier, Ms White had taken her son to Whittington A&E but he was not admitted after doctors decided that, although some of his behaviour was “odd”, he was coherent. They allowed him to go home.

When her son’s behaviour worsened, Ms White phoned Haringey’s crisis team but was offered “no support”, the jury said, other than being referred to the support and recovery team.

Ms White said she felt her concerns had been dismissed by Whittington A&E staff and Haringey mental health crisis team.

The jury agreed on the latter point, saying the “extremely inadequate response” by the crisis team “further precipitated Dominic’s mental health deterioration”.

He had started suffering mental health problems in 2011 when he returned to London after the relationship with his partner in Iceland, with whom he had a young son, broke down, the inquest heard.

He had been diagnosed with severe depression with psychotic symptoms and bipolar disorder and was admitted to a mental health unit in 2014 and 2015.

In a statement read to the jury, Ms White said her son had been “stable” since April 2015 and had been working full time as a security guard, but had become “sad and quiet” when his six-year-old son went back to Iceland in August 2016 following a visit to London.

Patience Davis, charge nurse at Whittington A&E on the day Mr White absconded, said that since his death the hospital has carried out a review and increased staffing levels.

Ms Hassell said she will write a Prevention of Future Deaths (PFD) notice which identifies necessary changes to prevent further loss of life.


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