A patient in a secure mental health unit died after another patient injected him with heroin smuggled in as a result of staff failing to identify the risk he posed, an inquest has ruled.
Desmond Maddix, 36, died on 1 July 2017 after another patient smuggled 10 syringes and heroin into the ward and injected him with an overdose.
HM assistant coroner Tom Stoate ruled at the inquest that his death was the result of a “failure of the most serious kind” by the East London NHS foundation trust, which runs Ash Ward acute psychiatric unit in Luton, where Maddix was a “highly vulnerable “inpatient for treatment-resistant paranoid schizophrenia.
Stoate confirmed the findings of an earlier criminal trial which determined that the fellow patient, referred to as Mr Z, had unlawfully killed Maddix – he is now serving a manslaughter sentence – but ruled that his death was also the result of ELFT’s failures in care and safeguarding, constituting neglect.
The coroner said these included “inadequate and inconsistent” risk assessments and observation of Mr Z, and the fact no staff had searched Mr Z upon returning from unescorted leave, despite his history of drug use and an earlier incident in which he supplied drugs and alcohol to vulnerable patients in the same ward, including to Maddix.
Hayley Chapman, the solicitor at Hodge Jones & Allen who represented Maddix’s family, said his death was “a tragedy” and “entirely preventable”.
“There is no doubt that staff in mental health inpatient settings do an extremely difficult job, yet the coroner’s finding of neglect reflects that the preventative measures required in this case were not advanced: they were part of Desmond’s basic care. We hope that lessons can be learned so that another family does not have to go through what Desmond’s have done,” she said.
Maddix was admitted to Ash Ward on 19 June 2017 after becoming severely unwell following a history of serious mental illness. Staff who cared for Maddix described him as a “quiet and lovely guy” who was quick to make people laugh.
The inquest at Luton and Bedfordshire coroner’s court heard how ward staff recognized Maddix as someone vulnerable to being led by others into taking illicit drugs as he did not have the capacity to make his own decisions.
A toxicology report suggested that Maddix had little or no tolerance for heroin and was not a regular user of the drug.
The court heard evidence from the ward manager that Mr Z’s risk to others should have been assessed as “high” on admission, which should have triggered further safeguards, including more frequent observations, but was instead classified as “low”.
The court heard further evidence about the conditions at Ash Ward, but the coroner considered that sufficient steps had been taken to improve the ward environment and did not issue a prevention of future deaths report.
The ELFT has since reduced patient beds from 27 to 18, increased the experience levels of nursing staff, and developed a plan to manage informal patients admitted to the wards, including risk assessments and leave.
The chief executive of ELFT, Paul Calaminus, said the trust extended its “sincere condolences” to Maddix’s family.
“Maddix died while he was under our care for which I am genuinely sorry. I want to assure his family and people admitted to our units that in the five years since this incident, changes have been implemented to improve the care, management and monitoring of inpatients to reduce risk,” he said.
Maddix’s family said: “Desmond who was a gentle giant and loved by many, has been and will continue to be greatly missed.
“Desmond went to Ash Ward as it was supposed to be the best place for him to recover fully, but unfortunately, it was the reason his life was taken too soon.”