Inquest finds neglect contributed to death of vulnerable Romford man

Inquest hears into death of Neil Challinor Mooney who died in November 2018.

A jury at the inquest into the death of Neil Challinor-Mooney concluded he died by suicide contributed to by neglect. - Credit: The Mooney family

An inquest concluded neglect contributed to the death of a vulnerable Romford man who was found unconscious in his room at Goodmayes Hospital.

Neil Challinor-Mooney, 51, died on November 18, 2018 after he had been detained at the hospital since November 1, following a significant deterioration of his mental health.

Born in Wales, Neil had schizophrenia and a number of physical ailments and his care was managed by the community health team of North East London NHS Foundation Trust (NELFT).

After being admitted to Turner Ward at Goodmayes Hospital under the Mental Health Act, the court heard evidence of numerous issues with Neil's care.

After five days of evidence, the inquest jury concluded Neil's death was caused by suicide contributed to by neglect. 

They also found that failures in communication, record keeping and inadequate preventative measures to keep Neil safe after disclosing his suicidal thoughts and method contributed to his death.

The court was told there was a poor recording of Neil's physical health issues with records describing him as having "no issues" despite three falls on the ward requiring his attendance at A&E.

Neil was allocated a named nurse on admission who went on planned annual leave the same day, and did not return until after Neil's death.

Most Read

There were clinical entries in Neil's records that were incorrect, the court was told, resulting in wrong information being used to inform his care and treatment.

It heard that, in one instance, the senior mental health nurse made an identical entry in Neil's electronic records as another nurse had made four days previously stating Neil was "improving" despite being an increasing risk to himself.

The same nurse amended Neil's records shortly after his death, claiming he was just fixing up spelling errors, and at the time an internal investigation was being compiled.

Nadia Persaud, senior coroner for the eastern district of London, confirmed she would be writing to the Nursing and Midwifery Council - the regulatory and disciplinary body for nursing in the UK - on the basis of this evidence. 

Neil's sister Marie Mooney-Evans said: "Neil was a family man above all else, and our family is devastated to have lost him in these circumstances.

“As a family, we remain deeply concerned that staff on Turner Ward failed to document and hand over crucial information relevant to Neil’s risk to himself, and to communicate and share that information either with each other or with us, Neil’s family.

"The jury’s conclusion of neglect reflects what we have always known." 

In the months leading up to his death, the inquest heard that there were frequent, poorly planned and communicated changes to Neil's care coordination.

The court heard Neil's long-term care coordinator left the trust in April 2018.

Neil had a further three different coordinators between then and October 2018.

There were no formal handovers between any of these three care coordinators, the hearing was told.

At the inquest, NELFT accepted that this failure to communicate with Neil would have caused him significant distress.

The court heard it also led to inadequate supervision of his mental health medication in the community, contributing to his subsequent mental health deterioration and the need for Neil to be admitted to hospital.

In the days leading up to his death, while at Goodmayes Hospital, Neil expressed suicide method thoughts to his psychiatrist but these were not included in the clinical notes and his risk was kept as moderate.

The coroner confirmed she will be sending a prevention of future deaths report to NELFT, highlighting her concerns. 

Tara Mulcair, of Birnberg Peirce solicitors, who represented the family, called the jury's findings "damning".

She felt the ruling confirmed that Neil was failed by NELFT and his death was preventable.

She said: "Ultimately, Neil paid for these failings with his life and my clients will bear the loss of Neil’s life for the rest of theirs.”

NELFT have been contacted for comment.

Call Samaritans for support on 116 123 or visit