Watford Hospital bosses must act after Harrow railway death
Hertfordshire health bosses must act after a man died by suicide straight after leaving hospital, a coroner has said
Hertfordshire health bosses must act after a man died by suicide straight after leaving hospital, a coroner has said.
Paz Ogbe-Millar, aged 30, died after he was hit by a high-speed train near Harrow and Wealdstone Station on December 2, 2021.
Mr Ogbe-Millar had arrived at Watford General Hospital earlier in the day after suffering a mental health-related emergency.
He claimed he was leaving hospital to smoke a cigarette, but staff did not accompany him.
He travelled into north London where he died later the same day.
A Prevention of Future Deaths report dated February 5, 2024, reveals West Hertfordshire Teaching Hospitals NHS Trust staff may not have followed Standard Operating Procedures.
They set out patients at moderate risk of self-harm, like Mr Ogbe-Millar, should be under continuous observation, the report notes.
A different document – the trust’s Emergency Department Adult Mental Health Pro Forma – demands staff “consider 15-minute special observations” for medium-risk patients.
“My concern is that the inconsistency between these two documents creates a risk that mental health patients at medium risk of self-harm awaiting assessment for their mental health condition in the Emergency Department may not be subjected to an appropriate level of observation,” North London coroner Tony Murphy wrote.
“Mr Ogbe-Millar died on December 2, 2021.
“He was 30 years old and described by his mother as highly intelligent, articulate, charming and well-read.
“For much of his life, Mr Ogbe-Millar was a heavy cannabis user, which led to his diagnosis with cannabis-induced psychosis in 2020.
“Mr Ogbe-Millar received treatment from community and in-patient mental health teams at various stages, including two hospital admissions.
“On being discharged from hospital in March 2021, he enjoyed a period free of cannabis and psychosis.
“He was able to work, attend Narcotics Anonymous and come off his medication.
“This led to his discharge from the community mental health team in June 2021.
“In November 2021, Mr Ogbe-Millar gave up his job and resumed using cannabis on a daily basis, leading to a relapse of his mental illness.”
Mr Ogbe-Millar’s mother sought help from the community mental health team, but he was discharged later the same month.
The community team had referred him to an organisation which did not specialise in psychosis and it failed to obtain information from his mother about the relapse, Mr Murphy wrote.
He added: “In the early hours of December 2, 2021, Mr Ogbe-Millar sent a text message to his mother saying ‘I’m sorry for my actions and I hope you all find peace’.
“His mother immediately telephoned the police who found Mr Ogbe-Millar at home redacted.
“The police took Mr Ogbe-Millar to the Emergency Department of Watford General Hospital… where there was an inadequate system for recording the information provided by the police to the hospital concerning his risk of self-harm.”
The report continues: “Despite Mr Ogbe-Millar’s risk of self-harm and the protective factor provided by the presence of his mother, she was not allowed to stay with him at the Emergency Department.
“She was required to leave by staff in breach of hospital policy.”
Mr Ogbe-Millar left the hospital shortly afterwards.
The NHS trust must respond to Mr Murphy by April 2, 2024.
A trust spokesperson 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 April 2 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.”