a black mental health The patient who died of a heroin overdose in hospital was examined only once every 14 hours despite an order that said he must be constantly checked, a poll has found.
Rullson Warner, 45, from North London he died on 9 March 2020 after using illicit drugs while a detained mental health patient at St Ann’s Hospital in Tottenham, north London.
An investigation at the North London Coroner’s Court identified serious failings, including a lack of medical observations and a failure of hospital staff to provide crucial and timely CPR when he went into cardiac arrest.
Staff reduced their observation levels from constant to every 15 minutes, without consulting a doctor as required, the court heard, while many of Mr Warner’s observations were recorded but never actually carried out.
Despite being a detained patient, Mr. Warner was somehow able to gain access and snort heroin, before passing out, which went almost unnoticed for 14 hours and passed away.
Carl Rix of Fosters Solicitors LLP, who represented Mr Warner’s family, said: “Rullson was admitted to St Ann’s as a safe haven. He was a vulnerable patient who needed to be protected. The fact that he was able to obtain illicit drugs in the room despite his history demonstrates to the family that the preventive measures in place at the time were not effective.
“It was a privilege to represent the Rullson family in this case, which has shown tremendous courage throughout this period, not only in pursuit of justice for Rullson, but also to ensure that no other family goes through what they do. have passed”.
On 26 February 2020, Mr Warner’s mother, Jurina Ikoloh, became concerned for his mental well-being and he was admitted to St Ann’s Hospital, run by the Barnet, Enfield and Haringey Mental Health Trust.
Upon arrival, Mr. Warner said that he had used illicit drugs in the past days and weeks. A risk assessment was conducted, including documentation of previous incidents in which he accessed medication in the room. Despite this, he was never monitored for this risk.
Rullson Warner, 45, from north London, died on 9 March 2020 after taking illicit drugs while a mental health patient was detained at St Ann’s Hospital in Tottenham, London.
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The following week, Ms. Ikoloh contacted the courtroom three times to express concern that Mr. Warner intended to access the drugs while he was still a patient. Despite documenting this in the records, there was no update to his risk assessment, nor did staff attempt to establish whether he had access to medication.
On March 4, 2020, he was formally detained under Article 5 (2) of the Mental Health Law, a short-term detention for evaluation. This was updated the next day to a section 2, which is a formal detention for further evaluation and treatment for up to 28 days.
Mr. Warner was also confined in a seclusion room from that date until March 7, 2020. After being searched upon entry, no illicit drugs were found. He was then seen by a consultant psychiatrist and placed back on the ward.
So it was decided that a doctor should monitor Mr. Warner every minute. However, the observations of him were reduced to every 15 minutes. The inquest heard that this decision was made without a doctor’s permission, for unknown reasons, in what was a breach of protocol.
The investigation showed CCTV footage from 4:37 pm on March 8 of Mr. Warner sitting on a chair in the common area, holding a woolen hat and holding it close to his face. The jury concluded that it was possible that he inhaled the heroin at the time.
He remained in the chair for over 14 hours and CCTV footage showed that he barely moved during this time and that none of the many 15-minute observations that were recorded in Mr Warner’s medical records and signed by staff, were recorded. actually did.
The images suggest that, during this period, a nurse only correctly observed Warner touching the patient’s shoulder at 8:46 pm, but he did not wake up or move. The next morning, at 6:42, he woke up and staggered around the common area before collapsing.
Ms Ikoloh said: “The last two years have been incredibly difficult without Rullson, and the need to get justice for him has weighed heavily on my shoulders.
“I was surprised to hear some of the evidence that emerged during the investigation. In particular, the fact that staff did not seek a doctor’s permission before lowering Rullson’s observation levels and the fact that none of his regular 15-minute observations were made overnight even though they were recorded. I only hope that steps will be taken to prevent such a tragedy from happening again.”
Blacks in Britain are four times more likely to be sectioned than whites.and Mr. Warner’s case has prompted renewed calls for this disparity to be urgently addressed to prevent further deaths.
“The last two years have been incredibly difficult without Rullson, and the need to get justice for him has weighed heavily on my shoulders,” said Jurina Ikoloh, mother of Rullson Warner.
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Deborah Coles, director of Inquest, said: “Families expect their loved ones to be served by mental health services. However, it is clear that Rullson’s death was premature and preventable, not only in the days before but in the months before when a drug rehabilitation program failed.
“This investigation highlights the failure to create a truly safe environment and meet basic needs, which is evident in too many mental health units nationwide.
“Black men are vastly overrepresented in mental health detention. Early intervention and access to specialized rehabilitation services are required to reduce this disparity and ensure that more deaths like Rullson’s are prevented.”
The inquiry comes as a new analysis revealed that the number of referrals for specialist mental health care has hit a record in England.
The Royal College of Psychiatrists said there were 4.3 million referrals to specialist mental health services in England during 2021, compared with 3.7 million in 2019.
“A worrying recent increase in arrests further confirms the urgent need for a fully funded reform of the Mental Health Act, to ensure that anyone who is experiencing a mental health crisis and is a risk to themselves is treated in a safe and therapeutic environment,” Rheian said. Davies, legal director of Mind.
“Structural racism continues to permeate the Mental Health Act: black people and black Britons are still far more likely to be detained under the Act, restrained against their will and more likely to be readmitted to hospital without adequate support. .
“To see racial equity within mental health services, there needs to be a greater commitment to anti-racism, addressing systemic biases in how people are treated, and challenging institutional racism head-on.”
A spokesperson for Barnet, Enfield and Haringey Mental Health NHS Trust said: “Our thoughts and condolences remain with the family and friends of Mr Warner.
“Following this tragic incident, we conducted a review to help identify any areas where we could improve. Since then, the specialists have worked with the staff of all the rooms to rehearse the emergency procedures for this type of incident.
“The ward that Mr. Warner was admitted to has now closed and patients are housed in the trust’s purpose-built unit, Blossom Court, where robust procedures are in place to prevent contraband items from being given to patients.
“Our intention is always to provide the best possible care. We will now closely examine the coroner’s findings to see if there are any further steps we can take.”
