A coroner who investigated a patient’s suicide, which happened hours after they left Watford General Hospital, has said that health professionals must act.
Paz Ogbe-Miller, who had a history of cannabis-induced psychosis, sent a text message to his mother on the morning of December 2, 2021, saying: “I’m sorry for my actions and I hope you all find peace.”
His mother called the police, who found Mr Ogbe-Miller at home and took him to the emergency department at Watford General Hospital. The inquest found that there was an inadequate system for recording the information police had provided to the hospital concerning his risk of self-harm.
Mr Ogbe-Miller’s mother was not allowed to stay with him at the emergency department while he waited for the Mental Health Liaison Team. Instead, she was required to leave by staff “in breach of hospital policy”.
Soon afterwards, and before the arrival of the mental health team, Mr Ogbe-Miller said he was stepping outside for a cigarette. He never returned.
Mr Ogbe-Miller died at just after 10pm that day at Harrow & Wealdstone station.
The coroner investigated why there was no system in place to report his risk of self-harm, the decision to not allow his mother to remain with him before the Mental Health Liaison Team arrived, and the decision not to accompany Mr Ogbe-Miller when he stepped out for a cigarette.
The coroner said: “I provided West Hertfordshire Teaching Hospitals (WHTH) NHS Trust’s solicitors with an opportunity to supply any information relevant to the concerns set out in this report during and after the inquest. My understanding is that the relevant parts of the policy guidance which have caused me concern remain in place.
“In my opinion, action should now be taken to prevent future deaths and I believe that your organisation has the power to take such action.”
A spokesperson for the hospital trust said: “We are reviewing the coroner’s comments in the prevention of future deaths report and the actions that need to be taken. We will respond in full by the 2 April deadline.
“Our sympathies are with Mr Ogbe-Millar’s family and we are keen to learn from the coroner’s review to improve our systems and processes.”
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