Another new Preventing Future Deaths report, again focusing on systems and processes around patients who abscond from mental health units whilst detained under the Mental Health Act 1983. Jayden Booroff died after absconding from the care of Essex mental health services in 2020 – he’d been a s2 patient on the ward and was considered very unwell and still psychotic at the point where he tailgated a nurse through not one but three secure doors. Once Jayden had absconded the nurse was unable to quickly raise notice of this, having left her alarm in her car outside the unit.
The PFD notice makes mention of confusion within the trust about the difference between a patient who had failed to return from hospital after an authorised period of leave (s17 MHA) and a patient who had absconded from detention where no period of leave had been in place. Jayden was in the second category and I can only infer from the point being made that someone considered incorrectly that he’d been in the former category. This report occurs at a point where there is an ongoing inquiry in to mental health care in Essex. For obvious reason, this particular tragedy has attracted considerable media attention, not least because Jayden was able to tailgate the nurse and leave with some ease, despite multiple obstacles to egress. Detail of the case is also available from the Inquest press release and from the Doughty Street chambers press release. They represented Jayden’s family during the inquest process.
The tailgating issue is significant for a number of reasons –
- This is far from the first time that Essex mental health services have known patients to go missing where they have left unchallenged – indeed, one of first times I read about Essex MH services was in the stated case of Savage v Essex Partnership Trust (2007) where a s3 patient’s family successfully sued the trust for a violation of Article 2 after they failed to stop Carol Savage from leaving and being able to die by suicide.
- The Doughty Street press release shows there had been 9 previous tailgating incidents at the Linden Centre, including from the ward where Jayden was detained.
- It all contributes to an inevitable frustration and feeling of futility whilst searching for people in desperate circumstances where lives may be at risk in the knowledge the absconding was, quite arguably, preventable.
The Essex Inquiry is examining, quite literally, 1,500 deaths between 2000-2020. Remember, although that is a long time scale of twenty years, it is just one mental health trust in England. You may remember reading of the Mazzers Review in to care at Southern Health which also reported on a failure to investigate over 1,000 unexpected deaths. Those numbers being as large as they are, it’s potentially easy for those who are uninvolved and who are vague on the details to see how some of them will come down to cases like Jayden’s – where a trust who has already been successfully sued for violation of Article 2 in the “Savage” case, is facing criticism for still enabling patients to walk out of detained mental health care by staff without alarms allowing tailgating.
And don’t we always hear from agencies after such outcomes from serious untoward events: lessons will be learned?
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2023
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