Archi Johnson · Prevention of Future Deaths report

On 14th November 2019 I commenced an investigation into the death of Archi Johnson.
The investigation concluded at the end of the inquest on 11th May 2022.
The conclusion of the inquest was suicide, the medical cause of death being hanging.

Archi was diagnosed with Schizoaffective Disorder with a history of depression,
self-harm and suicidal ideation. On 5th November 2019 Archi was voluntarily admitted
into Moorland View at North Devon District Hospital having told mental health professionals
that he had intrusive thoughts of taking his own life and he did not feel safe to go home.
During an admission on the ward two months earlier, Archi had attempted to take his own life
by ligaturing ████████
On admission, Archi’s risk level was assessed as medium and he was placed on
Level 1 observations.
On 7th November 2019 Archi was found hanging ████████████████████
████████████████████

1.Evidence was heard regarding the manner in which information crucial to the
formulation of risk assessments was recorded and shared:

a)Two types of risk assessments were completed, with no system to ensure that important
information is present on both;

b) The previous incident in which Archi had attempted to take his own life in very similar
circumstances on the ward was not clearly entered on the risk assessments used by staff
and therefore not known to a number of those responsible for his care;

c) Those responsible for his care accepted that the above incident was one of which they
would have wanted to have knowledge;

d) The absence of that information may have affected the subsequent decisions made
regarding the setting of risk level, observation level and removal of potentially
dangerous ligature items.