Jonathan Metzer recently represented the family of Rullson Warner at the inquest into his death on 9th March 2020 whilst on a psychiatric unit at St Ann’s Hospital in North London. The medical cause of death was consumption of a heroin overdose in the context of prescribed medications. The 4-day Article 2 inquest, heard by a jury, was held remotely at North London Coroner’s Court before HM Senior Coroner Andrew Walker.

Rullson was admitted to St Ann’s Hospital on 26th February 2020 after his mother raised concerns about his mental wellbeing. On admission a risk assessment was undertaken which included documenting previous incidents of Rullson accessing drugs whilst an inpatient on the ward. In the days following, Rullson was placed into seclusion for a period following an incident with another patient and his status was changed to a patient held formally under the Mental Health Act. Further, on three occasions during Rullson’s time on the ward his mother called and raised her concerns to staff that Rullson may have the intention of accessing drugs, but it does not appear that a specific plan was put in place to address this risk.

On 7th March Rullson was released from seclusion and placed on continuous observations. However, the jury concluded that at around 11am on 8th March his observations were reduced to every 15 minutes without the necessary permission of a doctor. It was found that if Rullson had remained on continuous observations, he would not have been able to take heroin and would not have died when he did.

At approximately 4.30pm on 8th March Rullson was sitting in the communal area and then appeared to fall unconscious. The jury concluded that it was possible that he inhaled heroin at that time. He remained in that state for approximately 14 hours, during which CCTV footage indicated that none of the recorded 15-minute observations actually took place.

Rullson awoke at around 6.45am the next morning, but as he walked over to the pool table he collapsed. As to the emergency response by staff, the jury concluded that there was a really serious failure to recognise cardiac arrest and delay in starting chest compressions, which possibly contributed to Rullson’s death. It was also found that there were further deficiencies in the CPR when it was undertaken.

HM Senior Coroner Andrew Walker is presently considering whether to make a Prevention of Future Deaths Report.

The inquest has been covered in the media here.

Jonathan Metzer was instructed by Carl Rix of Fosters Solicitors.