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Investigation and inquest
On 13th December 2018 Ms Nadia Persaud opened an investigation touching upon the death of Mr Rohan Dayal Singh, a man aged 31 years old.
Ms Persaud opened an inquest on 13th January 2019, the inquest was heard, before a jury commencing on 6th April 2021 and concluding on 16th April 2021.
The conclusion of the inquest was a short form conclusion of drug related death contributed to by neglect.
The medical cause of death was found to be: 1a. Ketamine, Gamma-Hydroxybutyrate, Lorazepam, Clonazepam and Promethazine toxicity.
Circumstances of the death
On the 10th December 2018, Mr Singh was detained by police under S.136 Mental Health Act. He was searched, no controlled substances were found on his person but a bracelet made of a length of knotted parachute cord, concealing a blade was seized.
Mr Singh was conveyed to a place of safety, a local A&E department where he was assessed, on the morning of 11th December 2018, to require treatment pursuant to S.2 Mental Health Act.
Mr Singh was transferred to a specialist mental health unit, where, following admission his property was searched. Again, no controlled drugs were discovered.
On the ward, Mr Singh’s behaviour was aggressive and challenging. The patient was made subject to 15 minute observations. The observations were not adequately undertaken and records of the observations were falsified.
On the morning of 13th December 2018 Mr Singh was restrained and administered rapid tranquillisation by intra-muscular injection.
Whilst under restraint, Mr Singh was subjected to a personal search and a small vial of liquid was found in his sock, when challenged as to its contents, Mr Singh replied, “nothing to worry about.” No steps were taken to establish the nature of the liquid. No other controlled drugs were found.
Following, rapid tranquillisation, appropriate mandated monitoring procedures were not followed and records, again, were falsified.
Later that morning Mr Singh was found unresponsive on the floor of his bedroom. Despite prompt CPR he could not be resuscitated and was declared dead.
Mr Singh was once again in possession of the bracelet confiscated by police on 10th December 2018.
A post- mortem examination was undertaken. During a skin level search the pathologist found, amongst other items, quantities of controlled drugs including cocaine, GBL and ketamine, concealed in Mr Singh’s underwear.
Toxicological analysis of blood samples taken from Mr Singh after death found toxic levels of GHB and ketamine, along with evidence of recent cocaine usage.
Coroner’s concerns
1. Rohan Singh died on a mental health ward, following his death he was found to be in possession of number of prohibited items including controlled drugs and a bracelet consisting of a ligature and a blade. Before admission into hospital, Rohan had been subject to a personal search by police officers when the bracelet was seized. During Rohan’s admission his property was subjected to a search and later he himself was searched for contraband, despite these steps he retained dangerous contraband.
2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation. The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.
Information checked against the published report and official responses