A black patient with mental health who died of a heroin overdose at the hospital was examined only once every 14 hours, although he was ordered to be constantly monitored.
Rullson Warner, 45, of North London, died on March 9, 2020 after using illicit drugs while being detained by a mental health patient at St Ann’s Hospital in Tottenham, North London.
An investigation at a coroner court in North London revealed serious failures, including a lack of medical observations and the failure of hospital staff to provide crucial and timely CPR when they had a cardiac arrest.
Staff reduced his observations from constant to every 15 minutes without consulting a doctor as needed, the court heard, while many of Mr. Warner’s observations were recorded but never actually took place.
Despite being a detained patient, Mr. Warner somehow managed to gain access to and inhale heroin before he fell unconscious, which remained almost unnoticed for 14 hours, and died.
Carl Rix of Fosters Solicitors LLP, who represented Mr. Warner’s family, said: “Rullson has been accepted to St Ann as a safe place. He was a vulnerable patient who needed to be protected. The fact that, despite his past, he managed to obtain illegal drugs at the ward shows the family that the preventive measures in force at the time were ineffective.
“I was honored to represent the Rullson family in this case, who during this period showed tremendous courage not only to achieve justice for Rullson, but also to ensure that no other families were exposed to what they were.”
On February 26, 2020, Mr. Warner’s mother, Jurina Ikoloh, became concerned about his well-being and was admitted to St Ann Hospital, run by Barnet, Enfield and Haringey Mental Health Trust.
Upon arrival, Mr. Warner said he had been taking illegal drugs in recent days and weeks. A risk assessment was carried out, which included documenting previous cases of access to drugs in the ward. Nevertheless, it has never been monitored in relation to this risk.
The following week, Ms. Ikoloh contacted the ward three times to express her concern that Mr. Warner intended to access drugs as a patient. Despite being documented in the records, his risk assessment was not updated, nor did the staff try to find out if he had access to drugs.
On 4 March 2020, he was formally detained under Section 5 (2) of the Mental Health Act – short-term detention. It was promoted to Section 2 the following day, which is a formal detention for further assessment and treatment for up to 28 days.
Mr. Warner was placed in an isolated room from that date until March 7, 2020. No illegal drugs were found after the search. He was then checked by a psychiatrist consultant and placed back on the ward.
It was then decided that the doctor should check on Mr. Warner every minute. However, his observations were shortened to every 15 minutes. The investigation found that this decision was made without the permission of a doctor for unknown reasons in violation of the protocol.
The investigation was shown by CCTV footage from 16:37 on March 8, when Mr. Warner is sitting in a chair in a common area, holding a woolen hat and bringing it closer to his face. The jury concluded that it was possible that he had inhaled heroin at this time.
He stayed in his chair for more than 14 hours, and CCTV footage showed that he had barely moved during this time and that none of the many 15-minute observations recorded in Mr. Warner’s medical records and signed by staff had actually taken place.
Footage suggests that during this time, Mr. Warner was properly observed by only one nurse who touched a patient’s shoulder at 20:46, but he did not wake up or move. The next morning, at 6:42, he woke up and walked uncertainly through the communal area before collapsing.
Mrs. Ikoloh said: “The last two years have been incredibly difficult without Rullson and the need for justice has weighed heavily on my shoulders.
“I was shocked to hear some evidence that emerged during the investigation.” In particular, the fact that the staff did not ask for a doctor’s permission before the level of Rullson’s observations was reduced, and the fact that none of his regular 15-minute observations were made overnight, even though they were recorded. I just hope that measures are taken to prevent such a tragedy from happening again. “
Blacks in Britain are four times more likely to be divided than whites, and Mr Warner’s case has raised new challenges to address this gap urgently to prevent further deaths.
Deborah Coles, director of Inquest, said: “Families expect mental health services to take care of their loved ones. However, it is clear that Rullson’s death was premature and preventable, not only in the previous days, but also in the previous months when the drug rehabilitation program failed.
“This investigation highlights the inability to create a truly safe environment and meet basic needs, as is evident in too many mental health units at the national level.
“Black people are extremely represented in terms of mental health. Early intervention and access to specialized rehabilitation services are needed to reduce this inequality and prevent further deaths such as Rullson’s. “
The investigation comes after a new analysis reveals that the number of referrals to specialist mental health care has reached a record high in England.
The Royal College of Psychiatrists said that in 2021, 4.3 million mental health specialists were recommended in England, compared with 3.7 million in 2019.
“The recent alarming increase in detainees further confirms the urgent need for a fully funded reform of the Mental Health Act to ensure that anyone experiencing a mental health crisis and at risk is treated in a safe and therapeutic environment,” Rheian said. Davies, head of Mind’s legal department, said.
“Structural racism continues to permeate the mental health law – blacks and blacks in the UK are increasingly likely to be detained under the law, curtailed against their will, and more likely to be re-admitted to hospital without the right support.
“If we want to see racial equality in mental health services, there must be an increased commitment to anti-racism, which addresses systemic prejudices in the way people are treated and directly faces institutional racism.”
Spokesman for Barnet, Enfield and Haringey Mental Health NHS Trust said: “Our thoughts and sympathies remain with Mr. Warner’s family and friends.
“After this tragic incident, we conducted a review to help identify areas for improvement. Since then, specialists have worked with staff in all departments to practice emergency procedures for this type of incident.
“The ward where Mr. Warner was admitted is now closed, and patients are instead housed in a trust unit, Blossom Court, where robust procedures are in place to prevent smuggled items from being passed on to patients.
“It is always our intention to provide the best possible care. We will now examine the coroner’s findings carefully to see if there are any further steps we can take. “