Glen Jordan

Hospital he was diagnosed as suffering from moderate to severe depression with underlying relationship difficulties. The Doctor concluded it was “was imperative to admit him to keep him safe and to assess his depression and consequently address his social and relational difficulties”.

1. Mr Jordan agreed to informal admission to Hospital.
2. A further clinical assessment took place by the on call duty doctor at Bushey

Fields Hospital on the 20 April 2016 where he was transferred to. On this occasion, the multidisciplinary risk assessment concluded his current risk was low for self-harm and suicide. He was subsequently placed on level one observation.

1. He was visited by his former partner during his admission in Hospital and a

holdall bag with some of his belongings was given to him. The contents of the bag were checked by staff and he was allowed to keep the bag in his room. Attached to this bag was a strap.

1. Over the course of his stay from 20 April through to 24 April 2016, he seemed to

be interacting with staff and involved in various activities including a cooking group.

1. On the 23 April 2016, he maintained a low profile and spent the majority of his

time on the ward.

1. He was seen by the on call doctor to explore his request to leave the ward and

to spend some time with ex-partner and children. He confirmed he still had thoughts of harming himself but no active intent or plan to act on these.

1. At around 2am on the morning of the 24 April 2016, he was discovered hanging

with a ligature (bag strap from his holdall bag found in his room).

1. He was taken to Hospital and pronounced deceased shortly afterwards.
2. The Trust held an investigation and concluded:

i) The root cause of the incident was found to be a spontaneous action undertaken by patient that was outside of the patient’s assessed risk/presentation and noted to be out of context with their regular behaviour ii) No issues were identified for any care and service delivery issues and in terms of recommendations and lessons learned, none were identified. iii) In terms of contributory factors, the investigation concluded that the availability of a suitable item (the strap from his bag) to compete the action was a contributing factor. There was however no clinical indications prior to the incident occurring, that such an action was likely and the clinical decision not to remove this item from the patient’s bag was appropriate and in line with recommended least restrictive principles. 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. – [IL1: PROTECT]