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Investigation and inquest
On 11/07/2017 I commenced an investigation into the death of Billie Jonathan LORD aged 26. The investigation concluded at the end of the inquest on 26th October 2018. The conclusion of the inquest was a narrative conclusion as follows:
Billie Lord died from suicide whilst suffering from psychosis.
He suffered from autism and a psychotic illness caused by the use of non-prescription drugs including cannabis. He was referred to the Milton Keynes Crisis team and came under the care of the Acute Home Treatment Team who saw him daily from 5th July 2017. On the 9th July 2017 he was admitted to the Campbell Centre in Milton Keynes as a voluntary patient after being arrested for an assault upon his mother. He was assessed and monitored by intermittent 15 minute observations on a Hasel Ward until he absconded at 04.30am on 11th July 2017 by breaking a window with a toilet that he wrenched from the wall. He climbed onto the railway line at Denbigh Hall and ran into the path of a high speed train at 08.40 and died from his resulting injuries.
Circumstances of the death
See Narrative conclusion above.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
During the course of the evidence I was informed by an independent expert that it is recognised that patients admitted to an in-patient mental health facility, such as the Campbell Centre, should be cared for in single rooms and that three bedded dormitory accommodation is inappropriate since in this particular case it added to the level of stress suffered by the patient. Consideration should be given to a review of the accommodation provided at the Campbell Centre, and whether alterations can be carried out to bring the accommodation up to modern standards as recommended by the Royal College of Psychiatrists.
