Ronald Gittens · Prevention of Future Deaths report

On the 12th April 2012 I opened an inquest touching the death of Ronald Gittens , 31 years old. The inquest concluded on the 22nd September 2014. The conclusion of the inquest was "Narrative", the medical case of death was 1a Cerebral Hypoxia 1b Hanging

On the 5th April 2012 Mr Gittens was brought by ambulance to St Thomas’ hospital when he had a passer by telephoned for an ambulance having seen and spoken to Mr Gittens in the street.

A doctor at St Thomas’ assessed Mr Gittens and Mr Gittens agreed to an informal admission and was placed on one-to-one observation. Had no bed been available at Chase Farm Hospital where Mr Gittens was to be transferred Mr Gittens would have been admitted to St Thomas’

Mr Gittens was transferred to Chase Farm Hospital where he was assessed again and plan was for an informal admission. Mr Gittens was left to wait for a bed and intermittently monitored. Staff at Chase Farm Hospital did not know that Mr Gittens had been on one-to-one observation prior to his transfer.

Mr Gittens left the hospital before being admitted.

Mr Gittens was found on the 7th April 2012 at his home having hanged himself using a length of rope from the loft hatch handle.

The delay in admitting Mr Gittens and the fact that Mr Gittens was not on one-to-one observation whilst waiting to be admitted contributed to Mr Gittens leaving the hospital, and bearing in mind Mr Gittens state of mind, to his death.

The transfer of acute psychiatric patients when no bed is available and

The use of CRHTT as a filter to prevent patients in need of a bed from having access to a bed.