Neglect contributed to the death of a Romford father on a mental health hospital ward in east London, a jury has found.

Winbourne Charles, 58, died in his room at Goodmayes Hospital on April 10 2021, having spent five months undergoing treatment for depression with psychotic symptoms.

Following a week-long inquest at Walthamstow Coroner's Court which ended last week, jurors took less than two hours to rule that Winbourne died from “suicide contributed to by neglect”.

They said Goodmayes Hospital failed to address Winbourne’s “obvious” risk of self-harm or medically intervene to protect him.

Following the jury’s findings, senior coroner for east London Graeme Irvine accused North East London NHS Foundation Trust (NELFT) of attempting to “cover up” evidence of its failures.

Mr Irvine said it was “utterly incomprehensible” that three internal reports produced by NELFT – which runs the hospital – did not mention a “smoking gun” of missed observations that could have saved Winbourne.

READ MORE: Coroner criticises nurses over Goodmayes Hospital death

He added: “It seems to me that this remarked upon a culture of impunity and that, unless someone sees there are consequences to their actions, nothing is going to change.

“I think witnesses who have given evidence to me in this inquest have not told the truth.”

Senior doctors had recently flagged the father-of-two as high risk due to the length of time he had been on the ward without losing his thoughts of self-harm.

Staff notes suggest that when ward staff found Winbourne dead in his room at 5.17pm, no one had checked on him for at least two hours, despite a requirement for hourly observations.

However, the coroner said he had “no faith” in those notes and “significant doubts” that anyone had checked on Winbourne earlier that day.

Suspicions about the conduct of hospital staff emerged at the scene of Winbourne’s death on April 11.

A police detective who responded that day told jurors he launched a criminal investigation after waiting for “a number of hours” to obtain basic evidence such as medical notes.

He said: “Initially it seemed unclear what had happened and, once we had CCTV, it added towards the fact that we needed to interview everyone to find out what had happened.” 

READ MORE: Grieving family files legal action against east London coroner service

Winbourne’s medical notes said that he was last seen by staff at 3.17pm.

However, during the inquest ward manager Mobolanle Adeusi said she had to warn staff not to “cut and paste” notes about when they had observed patients.

Matron Michael Donkor also admitted “dishonest” changes had been made to Winbourne’s medical notes in the 24 hours after he died to add in three observations.

Faced with questions about the accuracy of their notes, two ward staff who gave evidence declined to answer, instead invoking an inquest rule protecting them from saying something that might incriminate them.

Winbourne was described as a “vibrant, much-loved” family man who worked as a plasterer and lived in Romford with his wife and two children.

The court was told his mental health issues, which developed into paranoia, started in March 2020.

He was admitted to Goodmayes Hospital in September 2020 after a serious incident of self-harm but medical treatment had a limited impact on his condition, the inquest heard.

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Five days before he died, a hospital multi-disciplinary team assessing Winbourne’s risk level cut his observations from every fifteen minutes to hourly.

The team decided Winbourne posed a “low to moderate” risk of harm to himself as he had no “intents or active plans” to self-harm.

However, only a month earlier senior doctors had flagged the father-of-two as one of their most high-risk patients, noting that months of medication were “not decreasing risk”.

The coroner said the team’s assessment of risk was “completely at odds” with the view of one of those senior doctors, clinical psychologist Lisa Wood, who had said Winbourne’s delusions remained “consistent” throughout his time on the ward.

Consultant Dr Kurshid Tabussum, who was responsible for his medical care, said: “It was a team decision and at the time we had considered all the facts.”

However, the coroner criticised the doctor for her “meandering” and “difficult to grasp” evidence, which she gave over video-link.

Ms Adeusi also admitted she did not read Winbourne’s notes before the team meeting but told jurors she believed he posed “no risk” to himself.

None of the staff had undertaken safer observation training since 2019, she also admitted.

The family’s solicitor Tara Mulcair, from Birnberg Peirce, said the jury’s “damning finding” of neglect reflects the view always held by Winbourne’s family that his death was preventable.

She added: “Winbourne’s inquest has highlighted, sadly not for the first time, the systemic failings in risk management, communication and record-keeping in Goodmayes Hospital.

“Winbourne paid for these failings with his life and my clients will bear the loss of their husband and father’s life for the rest of theirs.

“The family remain gravely concerned that senior management at Goodmayes Hospital were not transparent in the trust’s internal investigation, or to the police, about the missed final observations of Winbourne. The trust has rightly apologised to the family.”

A spokesperson for NELFT said: “We would like to offer our heartfelt condolences to Mr Charles’ family and loved ones at this very difficult time.

“We are grateful to the coroner and the family for their time and patience during this detailed investigation. The trust has accepted there were shortcomings in the care of Mr Charles and is sincerely sorry for them.

“Since this incident, the trust has made many changes to its practice to help ensure this does not happen again. The trust continues to work hard to learn from mistakes made and provide a high level of care for the communities we serve.

“Again, our sincere apologies to the family of Mr Charles and hope that the inquest has answered any questions they may have.”

In the coming days, the coroner is expected to issue the trust with a prevention of future deaths report.

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