John Frank Henry LANSDOWNE · Prevention of Future Deaths report

On 22 May 2012, my assistant coroner, Selena Ruth Lynch, commenced an investigation into the death of John Frank Henry Lansdowne, aged 62.

The investigation concluded at the end of the inquest on 22 October 2013. The jury returned a narrative conclusion, which I have attached.

John Lansdowne was diagnosed with schizophrenia in 1980. He had been cared for by local psychiatric in patient and out patient services for at least eighteen years prior to his death.

On Tuesday, 15 May 2012, he was admitted to St Pancras Hospital under s3 of the Mental Health Act, at the time talking a great deal about taking his life. He had in 2010 and 2011 jumped in front of trains, sustaining very significant injuries on each occasion.

At 10.30pm on Friday, 18 May 2012, he was found submerged in the bath. Cardiopulmonary resuscitation was attempted and he was taken by ambulance to University College Hospital, but he died shortly thereafter.

1. The jury found that the times observations of Mr Lansdowne took place in the 45 minutes preceding his discovery were unclear, despite a nursing observation record setting these out.

2. There was confusion regarding the retrieval of the entirety of the medical/nursing records after Mr Lansdowne’s death, and one observation sheet was never recovered.

3. At inquest, there was a lack of consistency in the understanding of nursing staff on Laffan Ward at St Pancras Hospital, as to the exact requirements of intermittent observations when a patient is bathing.

4. Mr Lansdowne died in the bath, it is possible as a result of drowning. Mr Lansdowne’s family explained at inquest that in other hospitals where he had been treated, only walk in showers are used.