Coroner: Romford man's death followed 'unacceptable failure' in care

Barking Adult College, Ripple Road

An inquest into the death of Robert Burills was held at the Barking Adult College in Ripple Road on Wednesday, July 6 - Credit: Google Streetview

A Romford man died after an “unacceptable failure” in his care by a mental health trust, an inquest has heard.

However, coroner Nadia Persaud found there was insufficient evidence to conclude that the failure of North East London NHS Foundation Trust (NELFT) directly contributed to the death.

NELFT told the court it was "struggling" with short staffing at the time, but since the death had hired more recruits and would change policies. 

Robert Burills, 54, of Petersfield Avenue, Harold Hill, died on January 15.

An inquest on Wednesday, July 6, heard he died nine weeks after his medication was changed.

A psychiatrist had said Mr Burills, who had a history of attempting to take his own life, should be “closely monitored” by his NELFT care coordinator.

But the coordinator did not contact Mr Burills between his medication being changed on November 11, 2021, and his death.

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“I wasn’t happy with the mental health team because when they changed his medication, his [co-ordinator] didn’t call him even once to see how it was going,” Mr Burills’ fiancée Michelle Harvey testified.

“Not even a phone call, which I find appalling, really... He was let down by the system, in my opinion. He could still be here.”


“He was a happy-go-lucky person,” Ms Harvey told the inquest at Barking Adult College.

Mr Burills had struggled with his mental health for years, having made attempts on his life in the 1990s and 2000s.

For five years he had received regular injections of the same medication, but the court heard testimony from Ms Harvey and psychiatrist Diana Anchescu that in November 2021, Mr Burills asked to swap the jabs for oral medication.

Medication Change

At the time, said Dr Anchescu, Mr Burills was “extremely coherent”.

“He was very clear in what he wanted to address and request,” Dr Anchescu said.

Mr Burills was “very stable”, “had not been found psychotic for a number of years” and showed no signs that he was a risk to himself or others.

He was deemed “low risk”, but Dr Anchescu still asked he be “closely monitored” by his care coordinator.


“I probably should have been more specific in regards to the frequency of the care coordinator review appointments,” said Dr Anchescu.

But Mr Burill should have been monitored by his coordinator at least every three to four weeks, the court heard, so when Dr Anchescu requested close monitoring, that meant even more frequently than that.

Dr Anchescu said a high turnover of coordinators had made things “difficult”.

“It’s been a struggle,” she said.

Asked whether she felt the lack of contact with Mr Burills had been unacceptable, Dr Anchescu replied: “Yes.”

Barking Adult College, Ripple Road

Coroner Nadia Persaud agreed with two witnesses that there had been an 'unacceptable' failure in the care of Robert Burills by NELFT - Credit: Google Streetview


“I totally concur with that, and that’s something that we really took on board seriously,” testified Irvine Muronzi, an assistant director of NELFT in Havering.

He told the court an internal investigation found the problems in Mr Burills’ case came at a time when coordinators' “case load was very busy due to staff shortages”.

He said sickness from Covid-19 had also contributed to the issue, forcing staff to prioritise “high-risk” patients.

“We were struggling,” he told the court, and there was “a lack of senior support for more junior staff”.

But, he said, NELFT has since hired more employees, is advertising for more and is filling gaps with agency workers in the meantime.

He said policies would also be changed, requiring “clear instructions” on how regularly patients should be monitored.


Coroner Nadia Persaud asked Ms Harvey whether there had been any noticeable deterioration in Mr Burills’ mental health after his medication changed.

She said there had not, even on the day of his death.

“Everything was fine all day,” she said. “Laughing, joking... I don’t know what drove him to do this.”

“I recognise that there was an unacceptable failure in the lack of care coordination,” said Mrs Persaud.

But, she said, there was no clear evidence that proper monitoring of Mr Burills could have prevented his death.

She recorded a conclusion of suicide.

In a statement issued after the coroner's ruling, NELFT said: "We wish to offer our heartfelt condolences to Robert’s family, friends and loved ones at this very difficult time.

"The trust has internally reviewed the care provided to Robert as well as the impact the pandemic had on the service to identify learning and actions to improve the safety of care.

"The trust will further reflect on the coroner’s findings at the inquest to ensure that the quality of care at the trust continues to improve."

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