Vijaykumar Girishbhai Gadhavi · Prevention of Future Deaths report

On the 11th December 2020 I commenced an investigation into the death of Vijaykumar Girishbhai Gadhavi, age 33. The investigation concluded at the end of the inquest on 16th December 2021 with a narrative conclusion.

The narrative conclusion was that:

Vijaykumar Gadhavi died as a result of a drug overdose whilst he was an in-patient in hospital. He had a known risk of overdosing on hospital wards and had been placed under enhanced care (one to one supervision). There were numerous breaches of the enhanced care policy during the shift when Vijay was able to take the fatal, excessive amount of medication. The evidence does not reveal precisely how and when Vijay took the drug overdose. There is no evidence that he intended to bring about his death at that time.

Mr Gadhavi suffered from chronic pancreatitis, mild learning disability and possibly a persistent somatoform pain disorder (the latter was under investigation at the time of his death). In July and August 2020, whilst an in-patient at Whipps Cross Hospital and whilst under enhanced (1:1 care), Mr Gadhavi carried out a number of self-harming acts. These included overdoses and an attempt to jump from a hospital bridge.
On one occasion in August 2020, the member of staff allocated to provide 1:1 care to him, was found to be sleeping. In September 2020, Mr Gadhavi required admission to Whipps Cross Hospital again. There was no alert on his medical records to alert staff to the need for a risk assessment and risk management plan. Fortunately, he was recognised by a member of staff who had cared for him previously and enhanced care was put in place. Unfortunately, there were a number of breaches of the enhanced care policy. Mr Gadhavi was able to take a fatal overdose of medication whilst he was in-patient on the ward.

1. Datix reports were generated for the multiple self-harming incidents in July and August 2020. There was no evidence at the inquest, that action and learning had been put in place as a result of these incidents.
2. Despite the multiple risk incidents and foreseeability of future hospital admissions, there was no alert or flag placed on Mr Gadhavi’s records to alert new staff to the complexities and risk in his presentation.
3. Despite awareness of the previous overdoses on the ward, there was no itemised property list, including a list of medications.
4. The recommendation by the learning disability nurse were not fully put into practice. In particular, there was insufficient involvement of his family.
5. There were multiple breaches of the Enhanced Care Policy. There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer.