Man's suicide method thoughts were not in clinical notes, inquest hears
- Credit: The Mooney family
A vulnerable Romford man had expressed suicide method thoughts to his psychiatrist at Goodmayes Hospital but these were not included in the clinical notes and his risk was kept as moderate, an inquest has heard.
Barking Town Hall was told that Neil Challinor-Mooney, 51, died on November 18, 2018, after he was found unconscious in his room at Goodmayes Hospital two days before.
At the time of his death, Neil had been detained at the hospital since November 1, after a significant deterioration of his mental health.
The court heard that, while he was there, Neil told psychiatrist Dr Richard Duffett that he had suicidal thoughts and his risk assessment was changed from low to moderate.
It was told that in the days leading up to his death, Neil had mentioned methods of suicide but Dr Duffett failed to record these comments in the clinical notes.
Dr Duffett admitted that this should have been put in the notes.
The court heard how he defended not assessing Neil as high risk because his suicidal thoughts had been going on for some time.
Dr Duffett said increased observation can be extremely intrusive and can sometimes have a negative impact on a patient's recovery.
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An assistant psychologist testified Neil had also told him he had thoughts of a specific suicide method.
The court was told he recorded it in his notes and went so far as to underline it but, despite this, Neil's observation level did not change and staff were advised to do a level 2 (moderate) observation.
The clinical lead nurse testified he was concerned the risk assessment might change overnight.
He said he called around to get extra staff to come in to more closely observe Neil's care but could not find anyone available.
At the start of the inquest, Neil's sister Marie Mooney-Evans testified that her brother, who had schizophrenia and a number of physical ailments, had managed his mental health well throughout his life, until the final months when a series of events led him to a significant and rapid decline.
After having the same care coordinator for a number of years, the court heard Neil had three different ones over the course of a few months, which caused him to be anxious.
Neil informed one of his new care coordinators, managed by the community health team of North East London NHS Foundation Trust, that he had stopped taking his medication and had thrown it away.
The court heard that the coordinator did not take any action after hearing this.
It was told his long-term care coordinator had left a written handover note upon his departure but the other two did not.
In October 2018, one month before his death, Neil was admitted to King George Hospital for diabetes treatment.
The court heard that while there Neil had feelings of paranoia, thinking other patients wanted to kill him.
Marie told the court: "I spoke to staff daily pointing this out but I felt the doctors' response was very blasé and they would say everything is fine and he was taking his medication.
"After his discharge it was the worst I'd ever seen him."
He returned to his supported accommodation at Blackmore House in Junction Road but the court was told his paranoia got so bad he barricaded himself in his room.
On November 1, following an assessment, Neil was detained under the Mental Health Act and his sister took him to Goodmayes Hospital.
She said: "We were a family putting him in there thinking he'd be better off.
"We feel there were massive, massive failings.
"He was neglected by that ward [Turner Ward at Goodmayes Hospital]."
The jury has retired to consider its verdict.
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