David Ayontunde Walker · Prevention of Future Deaths report

On the 23rd December 2020 I commenced an investigation into the death of David Ayontunde Walker aged 27 years. The investigation concluded at the end of the inquest on 20th October 2021. The conclusion of the inquest was a narrative conclusion:

Mr Walker took his own life on the 27th November 2020. This was, in part, because risk information was not correctly shared between two treating mental health trusts; the risk of David taking his own life was not fully assessed and necessary precautions were not taken on his discharge from hospital on 23rd November 2020.

David Walker suffered from mental and behavioural disorder due to drug use. His mental health deteriorated from January 2020. In July 2020, David attended London Bridge with the intention of ████████. He was too scared ████████ and did not take any action at that time. Two days later he attended ████████. A member of the public called the emergency services and David was admitted to the Newham Centre for Mental Health (under East London Foundation Trust). David remained an in-patient until 11 August 2020. Very shortly after his discharge from hospital, David attended ████████ ████████. He was taken back to the Newham Centre for Mental Health where he was admitted for a further short period. During July and August 2020, David was also under the care of the community recovery team of North East London Foundation Trust. He had a care co-ordinator allocated to him by North East London Foundation Trust. This information about the care co-ordinator was available to East London Foundation Trust, but there was no contact with the North East London Foundation Trust care co-ordinator. The North East London Foundation Trust care co-ordinator did not elicit the risk information from David and did not make enquiries of East London Foundation Trust. On the 9 November 2020, David travelled to ████████ ████████████████████. He was admitted to a local hospital under section 2 of the Mental Health Act, and was transferred under section to Goodmayes Hospital (North East London Foundation Trust). David's mental health improved during the course of the admission. The in-patient team did not seek collateral information from East London Foundation Trust and were unaware of the incidents in July and August 2020. The discharge risk assessment was therefore, incomplete. Had the Consultant been aware of the prior incidents, she would have considered a longer inpatient admission; considered granting leave under the supervision of the home treatment team or discharge under the care of the home treatment team. Instead, David was discharged to the community recovery team. There was one telephone discussion with David on the 25 November 2020, by the team at Goodmayes Hospital. On the 27 November 2020, David's mental health appeared to deteriorate after a return to work interview. David was found ████████ ████████ during the evening of 27 November 2020. His life was pronounced extinct on scene. Police attended and deemed the circumstances as non-suspicious.

1. Between end of May 2020 to November 2020, Mr Walker was allocated four different care co-ordinators. There was evidence that only one of these care co-ordinators established a therapeutic relationship with Mr Walker. Many of the care co-ordinators were locum staff.

2. On admission to hospital on the 10th November 2020 no steps were taken to seek collateral information from other Trusts involved in the care of Mr Walker. Mr Walker had been under the care of East London Foundation Trust in July and August 2020 and this Trust held a great deal of vital risk information that should have been available to the North East London Foundation Trust team. There was no evidence that the admission check list included the requirement for collateral healthcare information to be sought.