Emmanuel Ladapo
23 Apr 2024 · Coroner Mary Hassell · Inner North London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of family engagement
“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: 04.03.21 regarding [name redacted]; and 17.03.21 regarding [name redacted]; and to your predecessor on: 11.01.16 regarding Efstratios Voukelatos; and 29.04.15 regarding [name redacted].”
2. omission of suicide risk assessment
“the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal”
3. failure to assess suicide risk during deteriorating mental state
“Mr [name redacted] was noted to have deteriorated by the time of his consultation on 19 January 2023, and he was still depressed on 16 February 2023, but the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal”
4. insufficient focus on suicide risk assessment
“I am concerned that the importance of exploring the suicide question does not feature highly enough in the consciousness of C&I staff”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“I heard evidence from the consultant psychiatrist responsible for Ms [name redacted] care at Crisis House that it is not routine for the crisis team to involve family members in the care of a patient.”
This report
“Mr [name redacted] lived with his sister, who wanted very much to be involved with his care. However, I did not hear any evidence of engagement with her by C&I, either:”