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Investigation and inquest
On 31 December 2020 I commenced an investigation into the death of Christopher Thomas Ace RYAN. The investigation concluded at the end of the inquest . The conclusion of the inquest was
Mr Christopher Thomas Ace Ryan was detained under section 3 of the mental health act in laurel ward of Queen Mary's Hospital, Roehampton.
In the days leading up to Mr Ryan's death hospital notes documented he was well, compliant in taking prescribed medication and following hospital regulations on escorted leave, returning on two prior occasions on the 21st and 22nd December 2020.
No apparent concerns in needing to change his risk assessment for future escorted leave.
On 23rd December 2020 Mr Ryan absconded from escorted leave and was reported missing to the police at 13.51 by the hospital staff. He was assessed as medium risk by the police.
Conclusion - Drugs related death
Cause of death -
1a Aspiration of stomach contents
1b Central nervous system depression
1c Combined drug intoxication
Circumstances of the death
Deceased was a S3. Mental health patient absconder and missing person from St Marys Hospital
Deceased has absconded from the ward and met with a friend (previous patient on the same ward) at New Malden railway station. Friend has agreed to let the deceased stay at his flat in Kingston. Deceased has bought heroin and smoked it, deceased underwent laboured breathing and lost consciousness. Friend of the deceased called LAS who arrived and carried out CPR to no avail.
Coroner’s concerns
Chris was known to abscond from secure mental health detention during periods of "escorted leave". He had left the care of the Trust on 6 occasions during his final 3 month detention and was known to purchase and take illicit drugs on these occasions. His Consultant had discussed this high risk behaviour with him on many occasions.
(1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients, and that the clinical staff were not aware of this. Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused. Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone?
Information checked against the published report and official responses