Coroner makes prevention of future deaths report to Department of Health



On Thursday, 5 April 2012, Ronnie Gittens was taken by ambulance to St Thomas’ hospital in London Bridge suffering a psychotic breakdown and expressing dark thoughts about ending his life.  A psychiatrist assessed him as being “for admission”.  His home hospital was Chase Farm in Barnet and staff at St Thomas’ were led to believe that there was a bed there.  He was therefore transferred to Chase Farm in the middle of the night by ambulance and handed over to Chase Farm staff.

Ronnie was left alone waiting in reception for a period of hours in the middle of the night whilst suffering from an acute psychiatric breakdown, pending assessment and admission.  He left the unit and was found 2 days later, on Easter Saturday, having hanged himself in his flat.  The delay in admitting him, and the failure to place him under 1:1 observation, contributed to his death.  The coroner did not record a finding of suicide.

Ronnie was 31 years old and had one child.

Her Majesty’s Coroner for North London has today, as is his statutory duty under Schedule 5 to the Coroners and Justice Act 2009, asked the Department of Health what action it proposes to take to address the risk of future deaths caused by the transfer of acute psychiatric patients when no bed is available.

Ben Rodgers represented the family at the inquest and also drafted written statements for the prevention of future deaths report. Ben writes the chapter on inquests in the 9 Gough Chambers publication, Clinical Negligence Claims and regularly acts in inquests.

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Ben Rodgers

Call 2007

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