Mr Alex Blake · Prevention of Future Deaths report

I opened an inquest into the death of Mr Alex Blake, who died on 24th June 2018 in Lambeth Hospital (Q1761-2018).

An investigation and inquest was opened on 29th June 2018 and was concluded on 27th June 2019. A jury was summoned. The medical cause of death was: Ia Heroin Toxicity

The jury concluded that he died from a self-administered heroin overdose whilst a sectioned in-patient under the care of South London & Maudsley Trust at Lambeth Hospital, sometime before 04.13 on 24.06.18.

The jury concluded that there were inadequate observations conducted on the night, which meant that his death went unnoticed for several hours, due to unsuitable record sheets, ineffective observations and lack of communication between staff. There was evidence that rigor mortis had begun when he was found, based on evidence of the attending paramedic.

The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used. She chose to wait until 06.00 to conduct a proper observation. She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead. Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless.

The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59.

The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible.

The evidence of these three witnesses cannot be said to be reliable. The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court.