Whipps Cross patient took fatal overdose under 'one to one supervision'On one occasion, someone meant to be supervising Vijay was found asleep
Whipps Cross Hospital must “take action” to prevent future deaths after a patient meant to be under direct supervision managed to take a fatal overdose on the ward.
East London coroner Nadia Persaud published her report last week on the death of 33-year-old Vijaykumar Gadhavi, known as Vijay, at the hospital in late 2020.
After a year-long inquest process, Ms Persaud concluded there was “no evidence” Vijay was trying to end his life but noted he “had a known risk of overdosing on hospital wards and had been placed under… one to one supervision”.
Her report reveals there were “numerous breaches of the enhanced care policy during the shift” Vijay took the overdose, adding it was unclear “precisely how and when” he managed to do so.
She wrote: “Mr Gadhavi suffered from chronic pancreatitis, mild learning disability and possibly a persistent somatoform pain disorder (the latter was under investigation at the time of his death).
“In July and August 2020, whilst an in-patient at Whipps Cross Hospital and while under enhanced (1:1 care), Mr Gadhavi carried out a number of self-harming acts. These included overdoses and an attempt to jump from a hospital bridge.
“On one occasion in August 2020, the member of staff allocated to provide 1:1 care to him was found to be sleeping.”
Vijay was re-admitted to Whipps Cross in September of that year and Ms Persaud noted there was “no alert on his medical records” about the risk he posed to himself.
She added: “Fortuitously, he was recognised by a member of staff who had cared for him previously and enhanced care was put in place.”
Ms Persaud felt compelled to write to Barts Health NHS Trust, which runs the hospital, warning them of “a risk that future deaths could occur unless action is taken”.
She questioned why there appeared to be no “action and learning” following Vijay’s “multiple self-harming incidents” at the hospital and why there was “no alert or flag” on his medical records about the risk he posed to himself.
Her report continues: “Despite awareness of the previous overdoses on the ward, there was no itemised property list, including a list of [his] medications.
“The recommendations by the learning disability nurse were not fully put into practice. In particular, there was insufficient involvement of his family.
“There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer.”
Barts Health now has until 26th April to respond to Ms Persaud’s concerns, explaining how they will prevent similar deaths in future.
Asked to comment on the report, a Barts spokesperson said: “We offer our sincere sympathies to the family of Mr Gadhavi.
"We are taking the concerns raised by the coroner very seriously and we will be responding with the actions we have taken and plan to take to prevent this happening again.”