Dominic Michael WHITE · Prevention of Future Deaths report

On 14 November 2016, one of my assistant coroners, William Dolman, commenced an investigation into the death of Dominic White aged 27 years. The investigation concluded at the end of the inquest on 19 May 2017. The jury made a narrative determination, a copy of which I attach.

Dominic White had diagnoses of bipolar affective disorder and psychosis, but had been well for some time. However, in the few days before his death he very rapidly deteriorated.

His parents took him to the emergency unit at the Whittington Hospital on Monday, 7 November; they called the crisis team at Canning Crescent for help on Tuesday, 8 November; and they returned to hospital with him via ambulance on Wednesday, 9 November.

He spent most of 9 November in the emergency unit and was assessed as requiring detention under section 2 of the Mental Health Act, but before being conveyed to a mental health hospital with space for him, he walked out of the hospital emergency unit where he had been assessed.

He was found the following day at an electricity substation, with injuries consistent with a fall from height. There was no evidence that any other person was involved in his death, but he lacked the necessary insight or intent to allow a determination of suicide to be a safe one.

1. I heard that, following Mr White’s death, the level of (mental health) observations of a patient at the Whittington Hospital Emergency Unit is now clearly documented.

However, I am not sure that there is yet a robust protocol in place to ensure that all relevant personnel (Whittington EU doctors, nurses and security officers; also visiting independent s12 doctors, BEH and C&I staff) are aware of the level.

My concern arises because sometimes, when anyone can look at a record, that nobody actually does.

2. The C&I approved mental health professional (AMHP) who gave Mr White permission to leave the hospital to go to McDonald’s, after the decision had been made to detain him under section 2 of the Mental Health Act, acknowledged that she should have discussed this first with a colleague.

However, she remained of the view at inquest that the decision itself had been the right one. Proof of this, she explained, was the fact that Mr White did return to the hospital from this visit.

Allowing leave in these circumstances was a very unusual step I am concerned at the lack of recognition, even so long after the event, that allowing a person to leave the hospital in these circumstances:

- was not necessarily the right one simply because the patient returned on this occasion (he left again within half an hour and never returned); and
- had the potential to lull others into a false sense of security about his risk of absconding.

The trust’s root cause analysis action plan merely describes the need to have legally authorised permission to leave, without addressing any question of how to shape clinical decision making.