Inquest highlights hospital neglect in suicide of mental patient

A mental hospital “contributed by neglect” to the death of a much-loved family man, an inquest found.

A jury heard that Neil Challinor-Mooney, 51, told staff at Goodmayes Hospital twice about his plan to commit suicide in the days leading up to his death in November 2018.

Despite this, staff at the Ilford hospital did not keep a closer eye on him or confiscate the item  he had told them he planned to – and eventually did – use to take his own life.

Mr Challinor-Mooney’s sister Marie Mooney told the court she felt Neil, who had paranoid schizophrenia, was “let down”, by the North East London Foundation Trust (NELFT), which runs Goodmayes Hospital, and the community care team that supported him before he was admitted.

Speaking after the jury returned a verdict of “suicide contributed to by neglect”, she said: “We knew Neil had been grossly let down, but we were still shocked at some of the evidence we heard.

“As a family, we remain deeply concerned that staff failed to document and hand over crucial information relevant to Neil’s risk to himself, and to communicate… either with each other or with us.

“The jury’s conclusion of neglect reflects what we have always known. Our family will continue to fight for policy changes to improve mental healthcare for vulnerable people like Neil.”

Speaking at the start of the inquest on May 4, Ms Mooney told the jury she had thought the hospital “was the best place” for her brother, adding: “I thought they could keep him safe and get him the help he so desperately needed.

“They never informed me he had repeatedly expressed a desire to kill himself. If I had been told, I would have gone straight there and maybe… we could have done something.

“Neil had the rest of his life ahead of him, he had a family that loved him hugely, he was a son, a brother and an uncle.”

Mr Challinor-Mooney was found unconscious in his room at Goodmayes Hospital on November 16 2018 and died in Queen’s Hospital of multiple organ failure two days later.

The inquest heard that, on November 13 and 14, he told staff he was hearing voices telling him to kill himself and indicated what he would use to do so.

Witnesses for the trust conceded during proceedings that staff should have – but did not – respond by confiscating the item and keeping a closer watch on him from that point.

Ms Mooney said her brother was “the happiest he had been in years” at the start of 2018, but things “started to go drastically wrong” after his long-term care co-ordinator left in April.

Mr Challinor-Mooney’s care co-ordinator was part of a community care team, also run by NELFT, which had supported him for many years but experienced rapid staff turnover that year.

The jury heard he had three new care co-ordinators between the end of April and his admission to Goodmayes Hospital in November, with no formal handovers and without his family’s knowledge.

This instability meant he was not properly monitored, with one care co-ordinator in late August failing to notify his doctor that he no longer seemed to be taking his medication.

Delivering their verdict, the jury spokesperson said that “inadequate record-keeping” by the community team “contributed to the deterioration” of Mr Challinor-Mooney’s mental health.

They added: “Neil was dependent on the mental health care services and we are all in agreement that there were a number of failures within the system.”

While the court heard evidence from NELFT about changes it has made since Mr Challinor-Mooney’s death, coroner Nadia Persaud noted she has “not seen any audits” proving these are in effect and still has “significant concerns”.

Ms Persaud indicated she will also refer the senior mental health nurse of Mr Challinor-Mooney‘s ward at Goodmayes Hospital to the Nursing and Midwifery Council after hearing evidence about the failures of care.

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Victoria Munro

Local Democracy Reporter