Juan David Martin · Prevention of Future Deaths report

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Issued 11 Jun 2024•Inner West London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns: 1
Recipients: 3
Responses found: 3
Stated actions: 31

Recipients and published responses

Department of Health and Social CareResponse found NHS South West London Integrated Care BoardResponse found South West London and St George'S Mental Health NHS TrustResponse found

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 24 April 2022 an investigation commenced into the death of Juan David Martin. The investigation concluded at the end of the inquest on 10 June 2024. The conclusion of the jury was suicide.

Circumstances of the death

Juan Martin was diagnosed with emotionally unstable personality disorder, depression, and anxiety. He was known to have suicidal ideation and had in the past attempted suicide. On 6 April 2022 he was detained by police under s.136 of the Mental Health Act 1983 at Beechy Head, Brighton having expressed a desire to cause harm to himself; he was taken to a place of safety. On 7 April 2022 he was informally held at the Lotus Assessment Suite at Springfield Hospital, London. On 10 April 2022 he expressed a desire to leave the Lotus Assessment Suite. He was then assessed under the Mental Health Act 1983 on 11 April 2022, and subsequently liable to be detained under s.2 of the Mental Health Act 1983, pending an appropriate bed. Accordingly, Juan Martin remained at the Lotus Assessment Suite held under common law. On 12 April 2022 he was seen by staff squeezing through a door leading to the external door of the unit; he was challenged by staff, who persuaded him to return. At approximately 15:00 on 12 April 2022 a bed became available on Ward 2 but was contingent upon another patient transferring out. This did not happen. According to witnesses at approximately 17:00 a bed became available on the Jupiter ward. There is no documentary evidence confirming this. By 19:03 the fire alarm was activating on the Lotus Assessment Suite triggered by steam from a shower. There was no fire evacuation policy for those liable to be detained and accordingly Juan Martin was evacuated along with other patients to an insecure area outside the Lotus Assessment Suite. He immediately ran off and was visible on CCTV in the vicinity of the hospital for approximately up to 8 minutes after. At 01:40 on 13 April his bank card was used to make a balance enquiry followed by a cash withdrawal of £11.99. At 11:25 on 13 April 2022 members of the public reported seeing a male on the wrong side of the fence ████████. Local police officers attended and at 11:57 he was witnessed by police officers allowing himself to fall. Despite emergency life support provided by officers on scene, an off-duty Emergency Department doctor and paramedics Juan Martin was confirmed deceased at 12:36. The medical cause of death was:
1a. Multiple Injuries; and
1b. Impact after descent from height.

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

Inadequate mental health bed capacity in London
Part of recurring concern: Insufficient psychiatric inpatient bed capacity

Stated actions 31

NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Invest in commissioning additional private-sector mental-health beds to mitigate current bed pressures while longer-term patient-flow work continues.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Embed a clinical prioritisation tool in acute-flow management to prioritise patient safety when allocating limited beds.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Implement discharge-planning best practices, including the 100-day challenge, high-impact interventions and ward workflow improvements.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Conduct collaborative discharge and patient-flow work with local-authority partners through the Strategic Operational Interface Programme.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Invest in community and crisis-prevention services to help patients remain well and avoid acute admission.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Provide intensive support to acute ward teams to identify flow barriers and improve safe, timely discharge practices.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Commission additional private-sector acute mental-health beds from a local provider.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Strengthen the Bed Management Policy and implement real-time electronic bed-status and waiting-list management.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Work with healthcare providers to reduce care-pathway delays, shorten stays and minimise out-of-area placements.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Transform the mental-health crisis offer by developing triage and rapid-access services for local emergency departments.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Review rehabilitation and supported-living settings with partners to improve access to onward care.
NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Commission stepdown hostel beds to support patient flow.
South West London and St George'S Mental Health NHS Trust
Review the local and pan-London AWOL policies and add missing-person and AWOL information, including a high-risk procedure flow chart, to the pan-London policy.
South West London and St George'S Mental Health NHS Trust
Conduct Lotus fire evacuation drills and incorporate further drills focusing on variations in evacuation procedures into routine arrangements.
South West London and St George'S Mental Health NHS Trust
Strengthen formal final-report issuing and require service lines to review, govern and assure that learning is shared and embedded.
South West London and St George'S Mental Health NHS Trust
Strengthen incident-management processes for capturing and allocating investigation actions.
South West London and St George'S Mental Health NHS Trust
Conduct Lotus walk-through AWOL drills to test staff awareness and response to the procedure.
South West London and St George'S Mental Health NHS Trust
Publish and distribute the revised AWOL policy to staff, clinical service lines and Lotus, seeking assurance that staff understand its requirements and procedures.
South West London and St George'S Mental Health NHS Trust
Add a dedicated sharing-learning section to the Patient Safety Incident Response Plan covering engagement with staff, patients and families.
South West London and St George'S Mental Health NHS Trust
Brief the central investigation team to review how investigation reports, findings and actions are shared throughout the investigation process.
South West London and St George'S Mental Health NHS Trust
Liaise with pan-London policy owners during the formal revision period to coordinate proposed AWOL policy changes.
South West London and St George'S Mental Health NHS Trust
Share and publish learning from the incident through the internal Monthly Learning Bulletin by September 2024.
South West London and St George'S Mental Health NHS Trust
Update corporate, local, team and fire warden training to cover detained patients, absconding risks and revised evacuation procedures.
South West London and St George'S Mental Health NHS Trust
Create an AWOL and fire scenario video and incorporate it into local and corporate induction during autumn 2024.
South West London and St George'S Mental Health NHS Trust
Revise the patient safety investigation template to require meaningful actions, implementation details, intended outcomes, assurance and monitoring.
South West London and St George'S Mental Health NHS Trust
Review internal review and sign-off processes for draft investigation reports, including the roles of relevant groups and committees.
South West London and St George'S Mental Health NHS Trust
Confirm and document Lotus staff understanding of legally compliant evacuation procedures for detained, assessable and high-risk patients, with arrangements for absent staff and new joiners.
Department of Health and Social Care
Deliver mental health care in the community through new models of care and support wherever possible.
Department of Health and Social Care
Provide specialist training for newly recruited mental health workers supporting people at risk of suicide.
Department of Health and Social Care
Recruit 8,500 new mental health workers across children’s and adult services.
Department of Health and Social Care
Publish and implement the five-year Suicide prevention strategy for England.

Respondent positions 2

NHS South West London Integrated Care Board and South West London and St George'S Mental Health NHS Trust
Full resolution of London’s acute mental health bed shortage is constrained by rising demand and limitations in funding and resources.
Unable to act
Department of Health and Social Care
Local mental health bed capacity and patient flow concerns are assigned to the relevant NHS Trust and Integrated Care Board.
Redirects responsibility

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised1

Inadequate mental health bed capacity in London

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.31

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

Stated actions 31

Respondent positions 2