John Lansdowne

On Tuesday, 15 May 2012, he was admitted to St Pancras Hospital under s3 of the Mental Health Act, at the time talking a great deal about taking his life. He had in 2010 and 2011 jumped in front of trains, sustaining very significant injuries on each occasion. At 10.30pm on Friday, 18 May 2012, he was found submerged in the bath. Cardiopulmonary resuscitation was attempted and he was taken by ambulance to University College Hospital, but he died shortly thereafter. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.

1. The jury found that the times observations of Mr Lansdowne took

place in the 45 minutes preceding his discovery were unclear, despite a nursing observation record setting these out.

1. There was confusion regarding the retrieval of the entirety of the

medical/nursing records after Mr Lansdowne’s death, and one observation sheet was never recovered.

1. At inquest, there was a lack of consistency in the understanding of

nursing staff on Laffan Ward at St Pancras Hospital, as to the exact requirements of intermittent observations when a patient is bathing.

1. Mr Lansdowne died in the bath, it is possible as a result of

drowning. Mr Lansdowne’s family explained at inquest that in other hospitals where he had been treated, only walk in showers are used. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and Camden & Islington NHS Trust have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 December 2013. I, the coroner, may extend