Paul Reeves
12 May 2025 · Coroner Ian Potter · Inner North London
The coroner's concerns
1. medication supervision in non-care home setting
“Maygrove Road, the supported accommodation, is not a care home and there is no expectation that staff at the accommodation will administer or supervise medication. Despite this, staff at the accommodation documented that they had collected Mr [name redacted]' medication 'for daily supervision'. Staff were aware that it was an expectation, from the mental health unit, that the accommodation staff should supervise Mr [name redacted]' compliance with his medication. There is no suggestion that the accommodation”
2. unreported agitation and property damage
“During a welfare check on Mr [name redacted] on the morning of 26 March 2024, it was noted that Mr [name redacted] was 'agitated' and that 'there were broken glasses and pulled electrical panel in his flat'. It was also noted that Mr [name redacted] 'didn't know what had happened'. The mental health unit contacted staff at Maygrove Road on 27 March 2024 and it was accepted in evidence that the concerns about Mr [name redacted]' behaviour and the damage caused to his flat were not mentioned to the mental health staff.”
3. delayed escalation of deteriorating mental state
“Although concerns regarding Mr [name redacted]' presentation (para 2 above) were not raised during the telephone call from mental health staff, the manager of Maygrove Road did send an email to Mr [name redacted]' care co- ordinator. That email raised health and safety concerns relating to the damage caused by Mr [name redacted] to his room/flat. However, it did contain phrases such as, 'he is not doing well' and he appears 'very unwell'. I found that an email (essentially headed as a health and safety matter) essentially”
4. unintervened crawling into roadway
“In the early morning of 28 March 2024 (approximately 07:13), the CCTV footage showed Mr [name redacted] crawling out of the front entrance to Maygrove Road, initially into the bin area and, a few minutes later, into the road. A support worker from Maygrove Road can be observed walking towards Mr [name redacted]. However, from the CCTV footage, the support worker appears to make limited attempts, if any, to engage Mr [name redacted] or block his path into the carriageway of the road.”