Sidi Bojang
1 Aug 2025 · Coroner Andrew Walker · North London
The coroner's concerns
1. discharge of mentally ill patient without psychiatrist review
“Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present. That a psychiatrist did not review the person presenting before discharge. The discharge of the person in these circumstances fell to a senior psychiatric nurse.”
2. unrecognized mental health crisis leading to fatal train collision
“Mr [name redacted] was clearly unwell and had attended the Accident and Emergency department the day before complaining of a "wooshing" sound and seeing flashes of light when he was triaged. He had attended with feelings of self-harm and had reported an attempt to cut his wrist and stab himself”