Lambeth man, 33, took his own life just 2 days after being sent home by NHS mental health team

A coroner has sounded the alarm about the “misleading” results of an NHS risk assessment after a man took his own life days after being seen by the crisis team. Jada Monoja, 33, from Lambeth, died in November 2020. An inquest held in April concluded it was a suicide, possibly while experiencing delusional and paranoid thoughts.

Jada, who had a history of paranoia and delusion, disclosed her suicidal thoughts to her mother on 15 November 2020, prompting her to call NHS 111. This was quickly transferred to mental health services and Jada was seen by a crisis assessment team as well. in the evening. He denied being suicidal, accepted treatment and was found to have capacity.

Jada was then referred to the Home Treatment Team where he was assessed and a care plan agreed on 16 November. But in the early hours of November 17, Jada’s mother woke up to find him missing from home. He was found unresponsive near Cleaver Square but emergency services were unable to save him and a goodbye note was found on him.

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Now Xavier Mooyaart, coroner for Inner North London, has written a report into preventing future deaths for South London and Maudsley NHS Foundation Trust, NHS England and the Health Secretary to highlight concerns about how the tool was used. risk assessment of the Trust. Mr Mooyaart cited several witnesses who said the tool on the online system was not used in accordance with the Trust’s policy.

The risk assessment tool was meant to be used at every admission, discharge or major risk event, but the inquiry heard evidence that “additional narrative” was added to the last assessment completed. This was used to set a benchmark against the patient’s previous presentation to assess their risk, but meant that the detailed indicators were not updated.

While Mr Mooyart acknowledged the utility of benchmarking, he shared concerns that the practice of updating rather than revising would make the assessment “misleading” because of incomplete or out-of-date information. “To the extent that risk assessment is used as a benchmarking tool, the impression given to the most recent viewer is likely to be incomplete and misleading,” he wrote.

He also said the potential benefit of using the benchmarking tool would be lost if the assessment it was based on was not clearly dated and flagged, the inquest heard.

“Heartfelt Condolences”

A spokesman for South London and Maudsley NHS Foundation Trust said: “We would like to send our sincere condolences to Mr Monoja’s family on behalf of the Trust. Risk assessment is central to the care and treatment we provide as an organization and we have completed actions since this incident in 2020 to ensure we address the concerns that were raised by HM Coroner.

“Over the past four years, we have updated our risk assessment tool based on clinical and research needs, improved the care provided by our home treatment teams and continued to provide ongoing training on risk assessment so that we can ensure that the latest learnings are incorporated into our framework. Although we can never eliminate all risks, our clinical teams work tirelessly to provide care and treatment to support the people who use our services.

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