Alice Kuzmenko appeared on behalf of the family of Mansoor Zaman, who was an informal patient at the Newham Mental Health Centre, managed by East London NHS Foundation Trust, at the time of his death. Alice was instructed by Monika Krzysztopolska of RWK Goodman.
Mansoor had a long history of mental health problems and mental health crises requiring inpatient admissions. In the lead up to his death, these presentations were more frequently being brought to the attention of psychiatric services, more frequently requiring admission for informal treatment, and the speed and tempo of his illness were increasing.
On 8 December 2024, Mansoor was admitted as an informal patient to Newham, on the background of suicidal ideation on the evening of 6 December 2024 (such that he was taken to a place of safety by the police under Section 136). Following admission, Mansoor demonstrated increasing risky behaviour, including absconding from the unit and requiring persuasion to return, an appointment with the duty doctor that was cut short due to increasing concerns of aggression, and an altercation with a member of staff. Thereafter, Mansoor absconded again. His body was located in the River Thames 19 days later.
Following a one-week Article 2 inquest, the jury concluded that Mansoor died by suicide. They further concluded that there was probable contribution to Mansoor’s death caused by the failure of the Nurse in Charge and duty doctor to use Section 5(4) and Section 5(2) of the Mental Health Act 1983 to detain Mansoor before he absconded the second time. Possible contributions were highlighted relating to a failure to increase the frequency of observations on Mansoor and a failure to undertake a new risk assessment following Mansoor’s first absconsion from the ward.
The Coroner has issued a Prevention of Further Death report addressed to East London NHS Foundation Trust and the Secretary of State for the Department of Health and Social Care having listed nine matters of concern, including failures to instigate authorisation under Section 5(4) and 5(2) of the Mental Health Act 1983, failures concerning documentation and appraisals of risk, and the dilatory response of staff on the ward to report Mansoor as a missing person.
