Henok Zaid GEBRSSLASIE · Prevention of Future Deaths report

On 13th August 2021 I commenced an investigation into the death of Henok Zaid GEBRSSLASIE (aged 23 years). The investigation concluded at the end of the inquest on 5th March 2025 at Coventry Coroners Court. The conclusion of the death of Mr GEBRSSLASIE was that death was “suicide and a narrative” by a copy of which I attach to this report.

Mr GEBRSSLASIE on the 2nd August 2021 was arrested by the police having been removed from a bus in possession of a plank of wood and oddly offering the police money sufficient for bus fare, this and his behaviour , throwing a road sign at officers precipitated his detention in police custody which gave rise to a mental health act assessment and his detention at the Caludon Centre. Part of his medical treatment included antipsychotic medication and sedation following an episode of violence. On 5th August 2021 Mr GEBRSSLASIE absconded from the Caludon Centre via a window, however he was located at his home address and returned to the Caludon Centre the next day and remained detained (under the Mental Health Act) on the Sherbourne Ward, the Psychiatric Intensive Care Unit, his behaviour leading staff to provide him with rip-proof clothing. There was an issue with language, involved communications achieved with an interpreter. Over the following days, in the context of medications provided, his mood was now adjudged seemingly more stable and by the 12th August 2021 Mr GEBRSSLASIE was allowed his own clothing, rip proof clothing removed. Mr GEBRSSLASIE was provide some hospital type pyjamas whist his personal clothing was being washed. Mr GEBRSSLASIE was on level 2 observations (every 15 minutes) and having expression a wish to go home it was communicated to him that his discharge from hospital was an ongoing process and not imminent. On 12th August 2021, the body of Mr GEBRSSLASIE was discovered in his bedroom (Bedroom 2) on Sherbourne Ward nearly 3 hours after his last observation. The deceased had a ligature ████████ around his neck and was partially suspended from the bedroom door. The Oxevision system camera (part of a research project, to assess whether new non-contact monitoring technology improves quality of care and safety for patients and staff in the patients’ rooms) captured the last interactions Mr GEBRSSLASIE has with staff, where upon moments after the bedroom door closed Mr GEBRSSLASIE then proceeded to use the same bedroom door as an anchor point for the ligature.

i. The inquest explored issues such ligature anchor points.

ii. It is known (and has been known for some years by the Coventry and Warwickshire Partnership NHS Trust) that the top of a door is a “high risk area” for ligatures in particular patients bedroom which have doors that may be locked by patients from the inside and thereby an unobserved patient area.

iii. The circumstances of this inquest touching upon the death of Henok GEBRSSLASIE in August 2021 accentuated this point.

iv. Such risks carrying with it a clear risk of death.

v. Since the incident it was known that door top alarms is “the way forward” as an environmental change that would mitigate such risk and referred to in a serious investigation report in April 2023, this “way forward” expressed in evidence during the inquest.

vi. There remains (now 42 months post Mr GEBRSSLASIEs death) no door top alarms on the patient bedroom doors at Sherbourne Ward, the Psychiatric Intensive Care Unit, at the Caludon Centre.

vii. The cumulative effect (there ‘seemingly’ no expediency to physically better mitigate this known environmental high-risk issue) is such that a concern as to future deaths exists as of March 2025.