Huseyin Hasan Erdogan · Prevention of Future Deaths report

On 18 June 2014, the senior coroner commenced an investigation into the death of Huseyin Hasan Erdogan, aged 26. The investigation concluded at the end of the inquest on 9 February 2015. The conclusion of the inquest was:
Medical cause of death: 1a. Cerebral hypoxia; 1b. Hanging and 2. Psychosis and depression.
Narrative conclusion summarised: Failure by the mental health practitioners of Barnet, Enfield and Haringey Mental Health NHS Trust to conduct, and to act upon, a fully-informed assessment of the deceased’s mental state, which contributed to his death, in that it resulted in no steps being taken by them to prevent his hanging.

Mr. Erdogan hanged himself on 4 June 2014 and, on 13 June 2014, died of cerebral hypoxia, which resulted directly from the hanging.

(The action plans to which I refer below accompanied my copy of the Root Cause Analysis Investigation Report approved by Barnet, Enfield and Haringey Mental Health NHS Trust on 17 September 2014. The Report was prepared following the Trust’s investigation into Mr. Erdogan’s death. The first Action Plan (so headed) appeared at pages 19 to 21 of the Report. The second, headed “Haringey CRHTT (SUI) Action Plan”, with pages numbered 1 to 4, appeared immediately after the first Action Plan. It is my understanding that both Action Plans were prepared with a view to ensuring that the recommendations set out in the Report would be implemented.)

(1) Although the first Action Plan set out six steps to be taken as “Action in Response to recommendations” and, although the “Date to be completed” for items 1 to 5 was stated to be “November 2014” there was, by the date of the inquest (over two months later) no evidence before me that any of those five steps had been completed.
(2) Although the Haringey Crisis Resolution Team (SUI) Action plan likewise set out nine steps to be taken (some of which corresponded very closely with those set out in the first Action Plan), and likewise set a “Date to be completed” of “November 2014”, there was, again, no evidence before me at the inquest that items numbers 1, and 3 to 9 had been completed.
(3) The risk of further deaths not being prevented will not be diminished if all outstanding steps have not already been completed, and if they are not completed without avoidable delay.