A coroner has sounded the alarm over the ‘misleading’ results of an NHS risk assessment after a man took his own life days after being seen by the crisis team. Jada Monoja, 33, of Lambeth, died in November 2020. An inquest held in April reached a conclusion of suicide, likely while experiencing delusional and paranoid thoughts.
Jada, who had a history of paranoia and delusion, disclosed his suicidal thoughts to his mum on November 15, 2020, prompting her to call NHS 111. This was quickly escalated to mental health services and Jada was seen by a Crisis Assessment Team the same evening. He denied remaining suicidal, agreed to treatment and was judged to have capacity.
Jada was then referred to the Home Treatment Team, where he was assessed and agreed a care plan on November 16. But in the early hours of November 17, Jada’s mum woke up and noticed him missing from their home. She found him unresponsive, nearby on Cleaver Square, but emergency services were unable to save him and a farewell note was found at his home.
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Now Xavier Mooyaart, a coroner for Inner North London, has written a prevention of future deaths report to South London and Maudsley NHS Foundation Trust, NHS England, and the Health Secretary to highlight concerns over how the Trust’s risk assessment tool was used. Mr Mooyaart cited multiple witnesses who said the tool on the online system was not used in line with the Trust’s policy.
The risk assessment tool was meant to be used on each admission, discharge, or major risk event, but the inquest heard evidence that ‘additional narrative’ was instead added to the last completed assessment. This was used to set a benchmark against the patient’s previous presentation, to gauge their risk, but it meant detailed indicators were not updated.
While Mr Mooyart recognised the usefulness of benchmarking, he shared concerns the practice of updating rather than reviewing would make the assessment ‘misleading’ due to incomplete or out-of-date information. “To the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent viewer is then likely to be incomplete and misleading,” he wrote.
He further said the potential benefit of using the tool for comparison would be lost if the assessment it was based on was not clearly dated and signposted, as was heard at the inquest.
‘Heartfelt condolences’
A spokesperson for South London and Maudsley NHS Foundation Trust said: “We would like to extend our heartfelt condolences to Mr Monoja’s family on behalf of the Trust. Risk assessment is at the core of the care and treatment we provide as an organisation and have completed actions since this incident in 2020 to ensure we address the concerns that have been raised by HM Coroner.
“Over the last four years, we have updated our risk assessment tool based on clinical need and research, improved the care delivered by our Home Treatment Teams and continue to provide ongoing training on risk assessment so we can ensure the latest learnings are embedded into our work. Whilst we can never eliminate all risk, our clinical teams work tirelessly to provide care and treatment to support people who use our services.”
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