Mr Warren James Green · Prevention of Future Deaths report

On 19 September 2024 I commenced an investigation into the death of Mr Warren James Green. The investigation concluded at the end of the Inquest on 28 November 2025 and the conclusion was that Mr Green died from 1(a) Traumatic Subdural Haemorrhage and 1(b) Skull Fracture, sustained following Mr Green jumping through the gap of a four-storey stairwell whilst on the acute ward. The conclusion was a narrative focused on both the delay in securing a psychiatric bed to move Mr Green to a mental health unit upon becoming fit for discharge from the acute ward and failings in safeguarding Mr Green from the high risk of self-harm, whilst he remained on the acute ward. Both of which probably more than minimally contributed to Mr Green’s sad death.

Mr Green was suffering from mental health issues and following a serious attempt on his life on 2 August 2024, Mr Green was admitted to hospital under the care of the Mid and South Essex NHS Foundation Trust. He became fit for discharge from the acute ward on 10 August 2024.

Although Mr Green was assessed as being liable for detention under section 2 of the Mental Health Act 1983, this detention was never formalised due to the delay in sourcing a psychiatric bed. Mr Green’s discharge to a psychiatric bed was delayed and he remained an impatient in the acute hospital.

On 20 August 2024, the Acute hospital failed to put in place the arm’s length supervision necessary to keep Mr Green safe and manage the high risk of self harm, due to funding authorisation not being provided. On the same day, whilst unsupervised, Mr Green was able to access an open fire escape stairwell placed at the far end of the T- shaped acute ward located in a low traffic and not overlooked area of the Ward without being seen by any staff and took his own life by jumping through the gap of a four-storey stairwell. Mr Green sustained a skull fracture which led to his death from traumatic subdural haemorrhage.

(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment
(2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff

The above shows a lacuna in terms of patients’ safety and safeguarding.

(3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultants oversight for these vulnerable patients.