Inquest finds neglect contributed to death of highly vulnerable man with mental illness

Monday 13 October 2014

An inquest has found that neglect contributed to the death of Christopher Ajayi, who died after being discharged from Maudsley Hospital in 2012 having been admitted under the Mental Health Act.

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An inquest has found that neglect contributed to the death of Christopher Ajayi, who died after being discharged from Maudsley Hospital in 2012 having been admitted under the Mental Health Act.

Catherine Oborne represented the family of Mr Ajayi, who died on 27 September 2012. He suffered from schizoaffective disorder and insulin-dependent type II diabetes, and had a history of self-neglect and homelessness.

Mr Ajayi was admitted under s.3 Mental Health Act 1983 to the Maudsley Hospital in May 2012. He was discharged in August 2012 without anyone checking whether he had a GP and without a GP or district nurse in place to organise his insulin medication. Mr Ajayi failed to attend numerous appointments with the community outpatient team but no home visit was carried out until nearly a month after he had been discharged, by which time he was almost certainly already dead. Though he was discharged with only a fortnight’s worth of insulin, no one checked on him after 14 days (after which his insulin would have run out). He was discharged to a bed and breakfast outside the borough with no support, despite having failed in bed and breakfast accommodation and despite having been assessed as needing low to medium accommodation support. Mr Ajayi’s body was eventually discovered in a severe state of decomposition, meaning that the pathologist was unable to determine the cause of death.

Following the medical evidence of a diabetes expert, the coroner ruled that Mr Ajayi had died of uncontrolled diabetes as well as his schizoaffective disorder and that this had been contributed to by neglect. In a narrative conclusion, the coroner found a total of nine failings, including four gross failings, by those responsible for his care. These included the failure to appoint a GP on Mr Ajayi’s discharge into the community and the failure to check on him after he had been discharged.

The coroner also agreed to write a Preventing Future Deaths report into the role and responsibility of the “care coordinator”: the nurse who has responsibility for an individual’s care at the transition point between inpatient and outpatient care.

Catherine was instructed by Chris Topping and Jenny Fraser of Broudie Jackson Canter solicitors.

Catherine Oborne is a member of the Garden Court Chambers Inquests Team.

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