Christopher McDonald, who suffered from a schizoaffective disorder, was pronounced dead on the afternoon of February 26, 2023 in the National Psychosis Unit (NPU) of Bethlem Royal Hospital after his leave from the unit was suspended after going AWOL.
An inquest was opened into Mr McDonald’s death in March 2023, with the investigation concluding with a seven-day hearing including a jury between March 17 and 25 earlier this year.
The coroner Sian Reeves raised concerns about South London and Maudsley (SLAM) NHS Foundation Trust, which operates Bethlem, in a Prevention of Future Deaths Report after hearing evidence at the inquest.
Mr McDonald was formally detained under section 3 of the Mental Health Act 1983 in November 2020 due to his diagnosis of schizoaffective disorder.
He was admitted to the Fitzmary 2 ward of the NPU at Bethlem Royal Hospital in July 2022.
Mr McDonald went AWOL from the hospital on February 24, 2023 and travelled to his mother’s home.
In such circumstances, an individualised assessment of whether it is appropriate to suspend section 17 leave under the Mental Health Act 1983—which allows a patient who is detained in a hospital to be granted leave of absence—should be carried out as per the trust’s own policies.
However, one SLAM NHS Foundation Trust staff member gave evidence at the inquest stating that it was “standard practice” and “protocol” that leave would be suspended.
There was no evidence at the hearing of any individualised assessment in Mr McDonald’s case being carried out.
The inquest also found no evidence to suggest that an action plan was drawn up or even considered by SLAM staff and police – another policy requirement.
Additionally, no member of NPU staff accompanied the police to escort Mr McDonald back to the ward after he was located at his mother’s address, something the coroner said could have “mitigated any potential distress”.
Upon his return to the ward on February 25, the coroner found that Mr McDonald’s “level of observation should have remained intermittent, but there is no evidence of it being reviewed”.
There was no evidence of any observations between 12.15pm and 9pm on that day, but he was reviewed by the duty doctor at 4.50pm.
The following afternoon at 1.30pm on February 26, Mr McDonald was found unresponsive. NPU staff started an emergency response but they did not find the ligature around Mr McDonald’s neck.
The coroner also found that there was “avoidable delay in the identification of the ligature by NPU staff” and that if NPU staff had communicated Mr McDonald’s “history of suicidal ideation involving ligature” to ambulance staff who arrived to resuscitate him, “it is possible the ligature would have been discovered and removed in the first instance, possibly increasing his chances of successful resuscitation”.
A senior paramedic from the London Ambulance Service identified and removed the ligature between 1.50pm and 1.55pm, but due to its continued presence it was not possible to administer successful CPR.
Mr McDonald was pronounced dead at 2.28pm on February 26, 2023.
SLAM NHS Foundation Trust’s Chief Operating Officer Ade Odunlade said: “We take the concerns raised by the Coroner in the inquest into the death of Christopher McDonald with the utmost seriousness and extend our deepest sympathies to all those affected.
“In response, the trust has taken immediate action to strengthen our practices and embed learning at both ward and organisational levels.”
The action the NHS has taken includes issuing “clear guidance” to ward clinicians and staff on the management of Section 17 leave for service users, reinforcing the need for a “personalised, case-by-case approach” to Section 17 leave decisions to ensure cancellations across the board are avoided, and reviewing and clarifying its AWOL policy with all relevant staff.
The trust has also presented the McDonald Case to its patient safety committee to promote “wider organisational learning and reflection” and it is continuing work to finalise its formal response to the Prevention of Future Deaths report, as requested by the Coroner.
Mr Odunlade added: “We continue to extend our deepest sympathies to Christopher’s family and friends.
“We remain fully committed to continuous learning, improving our practices, and upholding the safety, dignity, and wellbeing of the people in our care.”
Anyone can call the Samaritans charity for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
