Thiago Araujo · Prevention of Future Deaths report

On the 7th of February 2020 I opened an investigation touching upon the death of Thiago Araujo, aged 26 years old. I opened an inquest on the 14th February 2020. The inquest concluded on the 28th of January 2021.

The conclusion of the inquest was a narrative conclusion;

“Mr Thiago Vieira Strazzeri De Araujo deliberately ingested ████████ on 5 February 2020 which caused his death. Mr Araujo had been diagnosed with an emotionally unstable personality disorder which exhibited itself in; a preoccupation with death, emotional dysregulation, high risk behaviour, and at times - suicidal thoughts. Mr Araujo received community psychiatric care at the time of his death, he had disengaged from that care and consequently, there is no contemporary medical assessment of his mental state. In the days prior to his death he was observed by his family to suffer from psychotic delusions. It is not possible to satisfactorily determine his state of mind at the time of his death.”

The medical cause of death was;

1a ████████

On 5 February 2020 Mr Thiago Araujo was found deceased at his mother’s shared address. It was determined that Mr Araujo had consumed ████████ which caused his death.

At the time of his death Mr Araujo was under the care of the Camden and Islington NHS trust community recovery team.

1. On 24 January 2020 Mr Araujo had discharged himself from psychiatric inpatient care he was to be supervised by the Camden and Islington NHS trust crisis team. Mr Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the crisis team closed Mr Araujo’s referral. In the course of this closure no arrangements were made to address the risks presented by Mr Araujo.

2. Following Mr Araujo’s death it has become clear that the closure of his case by the crisis team was not permanent, and had Mr Araujo or his family approached the crisis team to reopen his case, steps could have been taken to reinstate crisis team support. Mr Araujo’s family were unaware of this facility.

3. Family and carers of patients diagnosed with emotionally unstable personality disorder do not receive support or education upon management of this diagnosis from Camden and Islington NHS Trust, unless the patient has been received for treatment by the personality disorder service.

4. By 4 February 2020 the Camden and Islington community recovery team identified an acute risk of suicide in Mr Araujo, faced with his non-compliance with community treatment they considered an admission into inpatient care. No actions were taken to affect this plan.

5. In evidence the community recovery team indicated that a factor in their inaction was the knowledge that arranging a section 135 mental health act 1983 warrant assessment would take two weeks. Such an assessment requires actions by an approved mental health practitioner from the local authority, two section 12 mental health act approved doctors, the assistance of the Metropolitan police and the local magistrates court to secure a warrant. A delay of 14 days in securing a mental health act assessment is in my opinion unacceptable.

6. In the days leading to Mr Araujo’s death his family became aware that he had made an online purchase of ████████ which was to be delivered to his father’s home address. Despite raising these issues with Camden and Islington NHS trust, the Metropolitan police and employees of the post office there appeared to be no process available to the family to escalate their concerns to prevent delivery of this package.