Editorial: Lessons must be learned from tragic cases at South London and Maudsley NHS Trust

(19 September, 2019) Editorials

Mr Blake's and Mr Canalp's cases are different - but have a tragic similarity around a lack of observation

10241Image: Stock

Nowhere should be safer for a person suffering poor mental health than hospital, but two cases we report on this week at South London and Maudsley (SLaM) Trust show that is not always necessarily the case.

SLaM provides mental health services across south London, including in Denmark Hill.

The deaths of Mr Blake and Mr Canalp are different, but one tragic similarity between them is striking. Both were not observed as they should have been, despite their vulnerabilities.

READ MORE: Alex Blake: Staff ‘may have provided false evidence’ over heroin overdose death at South London and Maudsley hospital

For Peckham’s Mr Canalp, Maudsley staff failed to place him on 1:1 observations while sectioned in an acute psychiatric ward – a gross failing which ultimately led to his death by suicide on March 8, 2018.

This amounted to neglect from the Trust, for which it has deeply apologised.

For 36-year-old Mr Blake, who suffered a history of drug abuse and mental illness, inadequate observations at Lambeth Hospital meant his death from a heroin overdose went unnoticed for several hours.

Evidence of rigor mortis was found by attending medics.

Even more worryingly, the senior coroner in that case has opined that three temporary staff on duty may have even falsified evidence in court over the observations conducted in the early morning of June 24, 2018.

Following July’s inquest into Mr Canalp’s death, campaigners compiled a list of other cases which they say show ‘failures and in some cases neglect’ at the Trust.

This paper has reported repeatedly on difficulties the Trust has faced. In November 2018, while rated good overall, acute adult wards were deemed ‘inadequate’ due to ‘breaches of fundamental standards of care’.

Staff afterwards admitted a ‘red line’ had been breached in care.

Since then the Trust has made significant improvements says the care watchdog – which praised the dedication of staff working across the Trust’s hospitals.

And to be sure, staff at the Trust are stuck between a rock and hard place when demand surges ever-higher while funding lags behind. They have rightly characterised this as a picture of ‘high need, low investment’. This too must be addressed.

INQUEST director, Deborah Coles, told this paper that the vital function of inquest hearings are to learn lessons for the future, most crucially to prevent future deaths.

We hope any lessons from the tragic cases of Mr Blake and Mr Canalp have already been learned at the South London and Maudsley Trust.

 

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