Mansoor’s story – uncovering failures through the inquest process

Mansoor had a long standing history of serious mental health problems and recurrent mental health crises, many of which had required inpatient care.

In the lead up to Mansoor’s death, his deteriorating mental health was coming to the attention of psychiatric services more regularly, resulting in repeated admissions for treatment. The pace and severity of his illness were escalating, signalling a growing level of risk to himself.

On 7 December 2024, Mansoor was detained by police after being found attempting to jump from a bridge. He was taken to hospital and assessed by mental health professionals under emergency powers, where he was described as distressed and experiencing suicidal thoughts and hallucinations. Mansoor agreed to be admitted to a psychiatric ward as an informal patient.

Following his transfer to Newham Mental Health Centre on 8 December, Mansoor was placed on enhanced intermittent observation, meaning he was required to be seen every 15 minutes due to concerns both about his risk of suicide and of attempting to abscond. It was recorded that Mansoor appeared unsettled and repeatedly requested to leave the ward, before he eventually left the secure facility through a fire exit. Staff intervened and were able to get Mansoor to return.

Upon his return, a review by the duty doctor was cut short due to escalating concerns about Mansoor’s aggression and an altercation with staff. Shortly afterwards, Mansoor was able to escape the ward undetected again through the same fire exit. Emergency services were not contacted until three hours later.

Mansoor’s body was recovered several weeks later, with the cause of death recorded as immersion in water.

At the inquest, Mansoor’s family were represented by RWK Goodman and barrister Alice Kuzmenko.

To ensure the inquest fully investigated the circumstances of Mansoor’s death, we liaised closely with the Coroner’s Court and carried out a detailed analysis of Mansoor’s extensive medical records, witness statements from staff, police records, and the Trust’s Patient Safety Incident Investigation (PSII) report.

Mansoor’s inquest was heard by a jury and engaged Article 2 (meaning an enhanced investigation took place). Through careful questioning by the Coroner and the family’s legal team, we were able to uncover deeply distressing evidence about missed opportunities and the Trust’s failure to protect Mansoor.

At the end of the inquest, the jury concluded that Mansoor died by suicide. The jury further found that there was a probable contribution to Mansoor’s death arising from the failure of both the Nurse in Charge and the Duty Doctor to exercise their powers under the Mental Health Act 1983 (MHA) to detain Mansoor prior to his second absconsion from the ward.

The jury highlighted factors that possibly contributed to Mansoor’s death including a failure to increase the frequency of Mansoor’s observations despite concerns about suicide risk and absconding; and a failure to carry out a fresh risk assessment following Mansoor’s first absconsion.

The jury also found that, whilst they did not believe the speed of reporting Mansoor absconding to the police contributed to his death, they did comment that it represented an unacceptable and shocking lack of adequate action.

After hearing all the evidence at the inquest, the family’s legal team made submissions that the Coroner ought to prepare a Prevention of Future Deaths Report. This is a public report that a Coroner makes where they are highlighting a concern that if improvements are not made, that other people may be at risk of dying in the future.

The Senior Coroner agreed with the family’s submissions and issued a Prevention of Further Death Report. In the report, the Coroner identified nine concerns which he felt, if not addressed, could pose a risk of future deaths to someone in Mansoor’s position. These included:

1. the failure of nurses on the ward to instigate an authorisation under S.5(4) MHA;
2. the failure of nursing staff on the ward to adequately document observations and care decisions;
3. the failure of Trust staff to reappraise the level of risk presented by Mansoor to himself and others in light of his erratic behaviour on 8th December 2024, specifically:
   a.  his escape from the ward by violently kicking the fire exit door;
   b.  his aggression toward the duty doctor during assessment;
   c.  his assault upon a member of ward staff.
4. the failure of Trust staff to re-assess the frequency and quality of observations that Mansoor should be subject to during the afternoon of 8th December 2024;
5. the failure of the duty doctor to act decisively and impose an authorisation under S.5 (2) MHA;
6. the dilatory response of staff on the ward to report Mansoor as a missing person to the police, an action that did not happen for almost three hours after it was known that he had absconded;
7. the categorisation of the risk presented by Mansoor as of a medium level by the nurse in charge when considering action to be taken after he absconded;
8. the use of the police 101 number as opposed to the required emergency 999 number to make the report;
9. the inadequacy of the Trust patient safety framework investigation which neither sought the recollections of treating staff, nor communicated the findings of the report to the same staff.

The final words in this article go to the heartfelt words of Mansoor’s family:

“Mansoor’s life reminds us of the profound beauty in simplicity—the desire for love, belonging, and peace. His story teaches us that kindness, even in the face of adversity, leaves an indelible mark on the hearts of others. Though his journey was heavily weighted by his struggles, his resilience and generosity continue to inspire. Mansoor’s legacy is a call to cherish relationships, to forgive freely, and to live with compassion. In remembering him, we are reminded that true strength lies not in perfection, but in the courage to love unconditionally and hope endlessly.”