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Investigation and inquest
On 28 May 2024, an investigation was commenced into the death of Kashim Ali, then aged 56 years. The investigation concluded at the end of an inquest heard by me on 21 October 2024 at Poplar Coroner’s Court.
The inquest concluded that Mr Ali died from natural causes. The medical cause of death was:
1a cardiac arrest
1b hypertensive heart disease
II schizophrenia, hyperkalaemia, type 2 diabetes mellitus
Circumstances of the death
Mr Ali was detained under section 3 of the Mental Health Act 1983, on Millharbour Ward at Mile End Hospital. His detention was for the purposes of providing treatment in relation to his longstanding diagnosis of ‘treatment resistant schizophrenia’.
On 21 May 2024, shortly after 09:00, Mr Ali was noted to be asleep in his bed. A few minutes later, he was noted to be totally unresponsive. Emergency procedures were followed, but attempts at resuscitation were not successful. Mr Ali died as a result of cardiac arrest.
Coroner’s concerns
1) Any National Early Warning Score (‘NEWS2’) should always be escalated. However, during Mr Ali’s time on Millharbour Ward he achieved a NEWS2 score on more than one occasion, which was not escalated to the nurse in charge for review.
While this was not a causative factor in Mr Ali’s death, I consider that it creates significant risk for other patients in future, if not addressed.
2) During part of his on Millharbour Ward, Mr Ali was on one-to-one observations, requiring him to always be within the sight of a dedicated member of staff. Following Mr Ali’s death, it transpired that during this period of observations, designated members of staff were noted to preoccupied with the use of their personal mobile telephones at times, and on one occasion, the designated member of staff was sat on a chair with their back to Mr Ali’s door.
While this was not a causative factor in Mr Ali’s death, I consider that such practices undermine patient safety and would place future patients at considerable risk.
3) The Trust noted, during its own serious incident investigation, that the quality of record keeping in relation to Mr Ali’s observations was not always accurate. Given the key role that accurate record-keeping plays in patient care within any healthcare setting, I formed the view that this also creates significant risk.
I heard evidence that the Trust is taking the above matters seriously and that they are going to be addressed at Board level. However, it was acknowledged that there was still work to do to address the risks identified.
Information checked against the published report and official responses