'We will continue to learn' says Radbourne Unit trust after patient took own life

The Radbourne Unit on the Royal Derby Hospital site
-Credit:Derby Telegraph


An NHS trust has admitted to failings in its care of a young man who fell to his death at a Derby hospital in 2023. A coroner found that Massaoud Belkouche, 20, died by suicide after jumping from a ledge at King's Treatment Centre on July 1, 2023, after requesting to go for a walk while he was detained under the Mental Health Act.

An inquest into Mr Belkouche's death was opened on July 20, 2023, and the week-long hearing was held in front of a jury at the Council House in the city centre from Monday, January 6 to Friday, January 10. The inquest looked to find how, when and where Mr Belkouche died, and to determine the circumstances surrounding his death.

Coroner Matthew Kewley heard that Mr Belkouche had a fairly normal childhood up until the age of 14, although his family did recognise he was very quiet and reclusive. He was an intelligent student but at this age he stopped attending school after expressing to his mum that the work was too much for him.

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It was noted that there was a decline in his mental health and wellbeing at this age. He had access to health professionals who assisted with mental health and austim, however, this apparently was difficult due to his lack of engagement.

He had mentioned to his mum in 2021 that he wanted to jump from Spider Island in Allenton. On May 21, 2023, Massaoud was taken to A&E after making his mum aware he had self-inflicted cuts to both sides of his neck. Massaoud was seen in A&E by the mental heath nurse where he expressed his desire to end his life.

After this conversation, it was concluded that he was to be admitted to the Radbourne Unit near Royal Derby Hospital under Section 2 of the Mental Health Act, which allows a patient to be admitted to hospital for a mental health assessment. The inquest heard that, initially, Mr Belkouche made minimal to no progress.

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A decision was made to further detain him under Section 3 of the same act - which allows a person to be admitted to hospital for treatment if their mental disorder is of a nature that requires treatment in hospital -which Mr Belkouche was not happy about. Following this decision, there was notable progress and he was granted leave from the ward.

This reportedly made his communication better and he showed general improvement. There was a further meeting on June 30 - which Massaoud refused to attend - where it was decided by his mother and healthcare professionals that he would be allowed Section 17 leave on July 3.

Section 17 of the act allows a patient to take leave from a hospital while detained under the Mental Health Act. On July 1, Massaoud requested to go for a walk, a decision which was allowed based on the success of his previous leave and morning observation. He had also began showing signs of better independence and an improved appetite along with a greater attempt at communication.

Massaoud saw an opportunity to leave the ward as the door was opened to allow other patients in. The occupational therapy assisant (OTA) was instructed to follow him and as he approached reception, the alarm was pulled and doors automatically locked. A plan was made to leave the building with five members of staff to ensure there was no absconsion attempt.

This plan was put in place as Massaoud appeared to be frustrated and it would have been beneficial to give him leave. This was a unanimous decision.

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Massaoud led the way to an embankment and sat down. He appeared to be calm and it was agreed that he would be left one-to-one with the OTA - but after a short while Massaoud suddenly stood up and ran.

The OTA followed him and, as instructed, immediately called the lead nurse. For a few moments she lost sight of him, but caught sight again and saw him on his phone. Attempts were made to talk Massaoud round but he continued to run towards the hospital, which CCTV confirms.

At this point, the OTA had completely lost sight of him and stood down as per instruction. At this point, the unit contacted family and security. The next known sighting was by a family who were attending Kings Treatment Centre.

He was on the wrong side of metal railings in a dangerous position. The family continued on into the hospital, but moments later heard a thud. Massaoud was seeing lying face down in the yard below. His mother informed hospital staff and an ambulance soon arrived. They then contacted police. It is noted that around this time, the ward had also contacted police.

He was stabilised at Royal Derby's A&E department, where it was decided he could receive better treatment at Nottingham's Queen's Medical Centre (QMC), to which he was transferred after observation. It became clear that his head injuries were unsurvivable and, with family consent, his life support was removed and he was pronounced deceased on the July 5, 2023. The trust admitted that there were failings in Massaoud's care, which were as follows.

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It admitted that Massaoud's risk assessment was not kept up to date during his admission, that there was no safety plan in place during his admission and that staff did not document care plans for Massaoud, however, the jury could not determine that these failings more than minimally contributed to his death.

Concluding the hearing, Coroner Matthew Kewley said: "On July 1, 2023, Massaoud absconded from the Radbourne Unit whilst he was detained under the Mental Health Act. He was seen at approximately 13:50 standing on the wrong side of the railings facing the walkway that leads to the Kings Treatment Centre.

"It is likely that Massaoud climbed over the railings to reach the ledge on the other side. In the balance of probability, we have concluded that Massaoud deliberately jumped from the ledge to end his own life. We find this because of these reasons: he was severely depressed and upset at his prolonged stay, he has a history of suicidal intentions, his back was facing the drop which shows a deliberate intention to be in danger as he was aware of the danger and he had ran away intentionally

"Massaoud died as a result of suicide. Massaoud died on July 5, 2023, at the QMC in Nottingham as a result of a head injury that was consistent with a fall from a height."

Tumi Banda, director of nursing, allied health professionals, quality and patient experience at Derbyshire Healthcare NHS Foundation Trust, said: “On behalf of the trust, I would like to offer my sincere condolences to Massaoud’s family and friends. We recognise there are elements of Massaoud’s care that should have been better, and we have been working hard to address these.

“A number of improvements have been put in place across our inpatient services since the sad events of 2023, including the introduction of a weekly audit to ensure people in our care have up-to-date care plans and risk assessments.

"Our arrangements for people leaving ward environments and our acute units have been revised to ensure a consistent approach across all areas. The trust has also appointed a suicide prevention lead to support our processes in keeping patients safe and assessing risk on an individualised basis. We will continue to learn and embed improvements into our services.”