62-year-old John Cushion ended his life while waiting for a mental health bed at Whipps Cross Hospital in July 2024, reports Sebastian Mann, Local Democracy Reporter
Warning: This article includes references to suicide
Multiple failures by the NHS led to a man taking his own life in a London A&E, an inquest has found.
62-year-old John Cushion, who lived in Redbridge, died waiting for a mental health bed at Whipps Cross Hospital in mid-July 2024.
Staff at the hospital failed to check on John for 50 minutes before he was found unresponsive in his cubicle, despite it being noted that he was alone with the lights off and the curtains drawn.
They also failed to remove items from John that he could use to harm himself, nor did they ensure he was put on one-to-one observations – despite telling mental health nurses he was feeling “100% suicidal”.
These were all found to have constituted “gross failures” by the NHS at an inquest held at East London Coroner’s Court, in Walthamstow, last week.
Area coroner Nadia Persaud said there was a “clear and direct causal connection” between these failures and John’s death.
Speaking after the inquest, John’s widow Francesca said she was “very grateful” to the coroner for the care taken when investigating his death.
His wife of nearly 30 years added: “I hope that lessons have been and will continue to be learned to ensure no other family has to go through what I and my daughters have over the last two years.”
The Leytonstone hospital’s A&E department is run by Barts Health NHS Trust. The North East London Foundation Trust (NELFT) oversees the psychiatric liaison service there and was responsible for the community mental health teams involved with John.
NELFT has extended its “heartfelt condolences” to his family, while Barts said it had “implemented a comprehensive improvement programme”.
John’s mental health had begun to worsen on 3rd July 2024 and he attempted to take his own life 15 days later. Francesca called 999 and he was taken to hospital for a physical health check and mental health assessment.
They arrived at Whipps Cross’ A&E department at around 2pm on Thursday, 18th July but were forced to wait in a corridor until the evening, when he was assessed by a nurse.
A doctor concluded he needed a mental health assessment, but it did not take place until the following day due to a failure in communication between staff.
The following day, he told mental health staff he was “100% suicidal” and nurses were told he needed to be placed under constant, one-to-one observation in A&E.
A second mental health assessment later concluded he should be admitted to a specialist psychiatric hospital and prevented from leaving the department for his own safety.
He was assigned a cubicle while waiting for a bed to become free, where he was found unresponsive on the evening of Friday, 19th July.
Francesca had characterised John during the inquest as being devoted to her and their two children, and said he was looking forward to retirement after many years of hard work.
Sophie Wells, a human rights solicitor with Leigh Day who represented the family, said: “Even in the context of the pressures on A&E departments and the mental health system, the scale of the failings in John’s care which the inquest uncovered, both in number and gravity, is shocking.
“I am pleased for John’s family that they now have a clearer understanding of what went so wrong for John, and that the coroner has recognised that a number of the failings met the very high threshold of neglect.
Following the inquest, a spokesperson for NELFT said: “We are deeply saddened by the tragic death of John and extend our heartfelt condolences to his family and loved ones.
“We continue to work closely with all partners to ensure that services are effective and to strengthen crisis pathways, risk assessment, escalation processes and support for people experiencing mental health crises.”
The Barts spokesperson said in full: “We extend our deepest condolences to Mr Cushion’s family and apologise for the failings in his care.
“We remain committed to providing the highest standard of care for all patients and have implemented a comprehensive improvement programme, working closely with NELFT and North East London ICB, to strengthen care and safety for patients presenting with mental health needs.”
Since the incident, Barts says it has introduced clearer procedures, stronger safeguards, and enhanced risk assessment processes to improve care for patients with mental health needs.
It also delivered mental health training for emergency department staff and established a new enhanced care team led by an experienced matron.
During the inquest, the coroner also raised concerns about the “honesty and integrity” of some of the evidence she heard.
She found that she did not consider the account of one member of staff from Barts to be “truthful and accurate” and told the trust to investigate her concerns further and report back to the court and John’s family.
Anyone feeling emotionally distressed or suicidal can call Samaritans for help on 116 123 or email [email protected]
Local news needs your support
We are proud that we were at the forefront of reporting on the recent local elections. We can’t do this without the support of our readers.
Independent news outlets like ours – reporting for the community without rich backers – are under threat of closure, turning British towns into news deserts.
If our coverage has helped you understand our community a little bit better, please consider supporting us with a monthly, yearly or one-off donation.
ACT NOW!
Monthly direct debit
Annual direct debit
£5 per month supporters get a digital copy of each month’s paper before anyone else, £10 per month supporters get a digital copy of each month’s paper before anyone else and a print copy posted to them each month. £50 annual supporters get a digital copy of each month's paper before anyone else.
More information on supporting us monthly or annually
More Information about donations
