Yahoo News Coroner sounds alarm after 5 suicides at NHS Trust where there was 'lack of engagement with families'
A coroner has hit out at an NHS trust in North London after linking multiple suicides to a lack of engagement with families. Mary Hassell, the senior coroner for Inner North London, also told Camden and Islington NHS Trust 'exploring the suicide question does not feature highly enough in the consciousness' of its staff after the fifth such death in nine years.
Emmanuel Ladapo, 24, sadly took his own life on March 13, 2023, after several hospital admissions related to his paranoid schizophrenia and depression. An inquest - which recorded a conclusion of suicide - heard he was treated by the Camden & Islington (C&I) early intervention service and was being treated by a C&I rehabilitation & recovery team when he died.
In a prevention of future deaths report sent to the Trust, Ms Hassell said Emmanuel lived with a sister who wanted to be part of his care. But, Ms Hassell said she heard no evidence of engagement with her by C&I, including after an incident in April 2022 when Emmanuel ordered a bolt gun on the internet which was only intercepted by the delivery driver.
Ms Hassell went on to cite four other prevention of future deaths reports, telling the Trust: "Lack of engagement with families is a story that I have heard often in inquests, and was the subject of prevention of future deaths reports that I sent to you on
[Grazyna Walczak in 2021, Ben O’Hara in 2021, Efstratios Voukelatos in 2016, and Finnulla Martin in 2015]."
She also highlighted a failure by Emmanuel's psychiatrist to ask him if he felt suicidal during consultations on January 19, 2023, and February 16, 2023. "This was the error of an individual, but it too is an omission that I have observed and written to C&I about before," she wrote.
Pointing out that an initial management review also failed to identify the omission, Ms Hassell added: "I am concerned that the importance of exploring the suicide question does not feature highly enough in the consciousness of C&I staff."
A spokesperson for the North London Mental Health Partnership said: "We would like to offer our deepest condolences, once again, to the family of Mr Ladapo. Following the publication of the Prevention of Future Death Report, we will be considering how to address the important issues highlighted and will address this further in our response to the coroner.”
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