Mental health patient fell to his death after fire alarm escape while waiting almost a week for a bed

A man who fell to his death during a fire alarm had already waited nearly a week for a bed on a mental health ward, a court heard. Juan David Martin died of multiple injuries due to the impact of a fall from height, leading a jury to reach a conclusion of suicide at an inquest held at Inner West London Coroners' Court this June.

Juan - who had emotionally unstable personality disorder, depression, and anxiety, and had attempted suicide in the past - was sectioned by police on April 6 2022 after expressing a desire to take his own life. He was admitted to the Lotus Assessment Suite at Springfield University Hospital in Tooting, part of South West London and St George's Mental Health Trust (SWLStG), on April 7.

On April 10, he said he wanted to leave, so the next day, on April 11, he was assessed again and became liable to be detained under Section 2 of the Mental Health Act. As he waited for a bed to become available, he was held at the hospital under common law. On April 12, he was caught trying to escape, by squeezing through a door towards an exit, and had to be persuaded back by staff.

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At around 3pm the same day, a bed became available on a ward, but only if another patient had left, and this did not happen. Then at 5pm another bed became available on a different ward, but there was no documented evidence to confirm this. By around 7pm, the fire alarm was activated on the Lotus suite, triggered by steam from a shower, which led to an evacuation of the building.

As there was no fire evacuation policy for those 'liable to be detained', like Juan, he was taken with other patients to an insecure area outside the suite. He fled straight away and could be seen on CCTV near the hospital around eight minutes later.

Around seven hours later, at 1:40am on April 13, his bank card was used to make a balance enquiry, followed by a withdrawal of £11.99. Some 16-and-a-half hours after his initial escape, at around 11:25am, members of the public reported seeing a male on the wrong side of the fence.

Local police officers raced to the scene, but at 11:57am Juan was seen falling. Despite efforts from officers and an off-duty A&E doctor, he was confirmed dead at 12:36pm.

'Bed capacity in London remains inadequate'

Following the inquest into his tragic death, assistant coroner Priya Malhotra sounded the alarm over the risk of future deaths while bed capacity in London 'remains inadequate', writing a report to the Chief Executive of SWLStG, Vanessa Ford, the Health Secretary, Victoria Atkins, and the NHS South West London Integrated Care Board, chaired by Mike Bell.

Ms Malhotra noted Juan was held informally for around six days before a bed became available and then quickly unavailable. The assistant coroner heard evidence from the Matron in Acute and Urgent Care that 'bed capacity remains an ongoing problem and has not been resolved', including a recent example where a patient waited seven days in A&E for a mental health bed.

The Matron also said the process to free up a bed requires a decision at a high level and that moving patients around 'amplified' the capacity issue.

"Based on the evidence heard, my principal concern is that bed capacity in London remains inadequate. Whilst some action may have been taken by the Trust to better triage the need for beds it is insufficient to resolve the problem," wrote Ms Malhotra.

"It follows there is a genuine risk of future deaths directly connected to a shortage of mental health bed spaces in London unless further action is taken."

'Extremely important patients get care quickly as possible'

A spokesperson for South West London and St George’s Mental Health NHS Trust said: “We are deeply sorry that our standards of care fell below those that we strive to achieve when this sad incident took place. Our thoughts are with the loved ones of JM at this difficult time.

“It is extremely important to ensure all our patients get the care they need as quickly as possible. We have been working hard to find new and better ways to do this, including with our partners across the South West London system, to develop a better system to make sure beds are quickly assigned to those patients who are most in need of our care.”

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