Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0081, written 11 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Feb 2025 |
|---|---|
| Reference | 2025-0081 |
| Deceased | Nicholas J’Dourou |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , President of the Royal College of Psychiatrists 21 Prescot Street London E1 8BB 1 CORONER I am R Brittain, Assistant Coroner for Inner London North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATIONS and INQUESTS Nicholas J’Dourou (date of birth 29 August 1977) died on 15 April 2024, whilst admitted as a voluntary patient at Highgate Acute Mental Health Centre (‘Highgate’). He died from asphyxiation which arose from the placement of a ligature around his neck. His death was contributed to by a diagnosis of Bipolar Affective Disorder. I heard the inquest into his death on 24 January 2025 and reached the conclusion of suicide. 4 CIRCUMSTANCES OF THE DEATH Nicholas had long-standing mental health diagnoses and had been detained under the Mental Health Act on several previous occasions. His mood deteriorated at the beginning of 2024. He was admitted to Highgate in early April, after initial failed attempts to improve his mental health in the community setting, through altering his medication. On review by the ward consultant, his background diagnosis of Schizoaffective disorder was queried and a diagnosis of Bipolar Affective Disorder was favoured. He was under ‘general observations’, meaning that staff were supposed to be monitoring him on an hourly basis. Sadly, on the late morning of the 15 April, he was found in his room with a ligature around his neck. Signs indicated that he died several hours previously. After inspection of CCTV and records of supposed observations, it was apparent that staff had not monitored Nicholas as had been intended. However, it was not possible to conclude that this lack of monitoring contributed to his death. 5 CORONER’S CONCERNS During the course of this inquest the evidence revealed matters giving rise to concern. In 1 my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN following the inquest into Nicholas’ death were as follows: 1. I heard evidence that cross-titration of medication, when changing from one regimen to another, is commonplace in psychiatric care but that how to undertake this process is determined predominantly by each individual prescriber’s own practice, rather than any local or national guidance. The local psychiatric Trust provided evidence that they were in the process of developing local guidance. However, this was proving to be complicated, owing to the range of settings in which cross-titration may be carried-out (i.e. primary care, community psychiatry care, in-patient care), the complexity of the medications prescribed and a lack of evidence regarding how this should be undertaken. I am concerned that this commonplace and important process is seemingly undertaken on the basis of limited consensus and that the variation in care provided could result in future deaths. 2. I heard evidence that the local psychiatric Trust had undertaken a trial of electronic patient observation (i.e. automated monitoring of respiratory rate, temperature) but that this had been discontinued, owing to patient complaints regarding invasion of privacy. The issue of privacy and electronic monitoring on psychiatric wards is clearly a complex issue. However, in circumstances such as Nicholas’ death, I am concerned that the lack of patient observation could result in future deaths. Regarding both of the above concerns, I heard evidence that the Royal College of Psychiatrists has not produced any formal guidance regarding cross-titration and use of electronic monitoring and that decision-making is ad hoc, based on individual/local practice. 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressee has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 April 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, Nicholas’ family, the hospital Trust and the CQC. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful 2 or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 11 February 2025 Assistant Coroner R Brittain 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Date: 24 June 2025 Dear Dr Brittain Re: Nicholas J’Dourou (Regulation 28: Report to Prevent Future Deaths). Thank you for sending this Regulation 28 Report to the Royal College of Psychiatrists regarding the death of Nicholas J’Dourou. We are grateful for the opportunity to comment upon this report but before doing that, we would like to extend our deepest sympathies to the family and loved ones of Nicholas. The Royal College of Psychiatrists (RCPsych) is the professional medical body responsible for supporting psychiatrists. The College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. The College does not work on the care of individuals and are therefore not able to comment on the specific circumstances surrounding the case of the death of Nicholas J’Dourou. However, we have considered your findings and have the following comments to make in relation to the two issues that you raise. 1. On the issue of cross titration, the College recognises that an effective understanding of how to do this by clinicians is crucial as part of a safe prescribing regime. While not necessarily consolidated as part of one specific document on the topic, the College has provided advice to clinicians and patients on this issue, particularly in the context of antidepressants and anti- psychotics. Examples of publications that do cover this to some extent include: • The risks and benefits of high dose anti-psychotic medication college- report-cr190.pdf • Stopping Antidepressants, a resource for patients Stopping antidepressants In addition, we have supported, promoted and fed into a number of other pieces of relevant work, the most prominent of which are probably the Maudsley Prescribing Guidelines, which we know many clinicians and trusts use, these for example have cross-titration tables for many years, particularly antidepressants. However we are always looking at ways that we can improve the quality, standards and the safety of care within mental health services. That is why we have indicated that we intend to increase our visibility in the space of safe medication and prescribing. Work we are currently doing around Clozapine, which started with learnings from a death elsewhere in the country is an example of this. Although the concerns in that case were not directly aimed at the College, we recognised our responsibility to provide evidence-based advice on the safe prescribing and monitoring of Clozapine. The output of this work is due later this year. Please be assured that we will also use mechanisms to communicate any risks and best practice to our members through our College Newsletters, Faculty specific communications and any other opportunity where we can make this issue more widely known. We will also, where possible, raise it with mental health organisations themselves as well as those who have responsibility and oversight for the mental health system and who will have routes by which this information can be disseminated. This PFD will be added to the range of material we use to inform our priorities in this area. 2. On the second point around the use of video technology when observing patients, we do believe that more needs to happen in the context of research to understand when such technology might have a positive impact and what safeguards are needed. For example, in a short statement we made in January this year we made clear such technology must always be based on what is in the clinical interests of the patient, never to be used to address things like staff shortages. While advocating for such an approach and calling for more research in this area, we believe that it is for those with the levers to drive consistent practice in this area as well as having access to the technical expertise which is needed as part of understanding the role of this technology. That is why we have over the last year sought through work with NHS England to provide more advice in this area and were delighted earlier this year that they published principles which all trusts should use when considering this and other technologies NHS England » Principles for using digital technologies in mental health inpatient treatment and care. I do hope that this response is helpful, please come back to us if you would like to discuss any aspects of it. Yours sincerely, Senior Policy and Standards Manager Royal College of Psychiatrists
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