Coroner urges more patient checks
Friday 30th August 2013, 5:30PM BST.
A pensioner with mental health issues who killed himself the day after being admitted to a care home should have been checked by staff more often, a coroner said today.
Tin-Sang Li, 83, had been able to lock himself in his room at Norwood Green Care Home in west London, despite staff knowing of his history of depression.
A care worker at the Southall home had to force entry to the room, where retired head chef Mr Li was found behind the door, as they could not find a master key.
The inquest at West London Coroner’s Court heard staff members failed to cut down Mr Li, check a pulse or try to revive him, with a nurse instead rushing off to call police while her colleagues described themselves as being too shocked to act.
However the inquest was told it would have been too late to save him.
Hours earlier, Farai Kamombo, the nurse on duty that night, had reassessed his level of depression from zero, meaning he was at no risk, to one, identifying that he had depression, after having looked at his notes.
If he had been initially assessed as having a history of depression upon admission the previous day, he would have been placed in a room that could not lock from the inside and on a floor where checks were carried out more frequently, up to once every half hour, the inquest heard.
Checks had been carried out at 2am and 5am, when staff nurse Kamombo spoke to Mr Li, but she did not see him.
However at around 8am, she found his door would not open and he did not respond when she called.
Assistant coroner Lorna Tagliavini recorded a verdict that: “Mr Li took his own life, contributed to by failing to carry out any frequent and regular observations having regard to both his status as a new resident and his increased level of depression.”
Ms Tagliavini said while Mr Li’s life could not have been saved, as police arrived shortly afterwards and reported his body was cold and stiff, she was concerned at the lack of reaction from staff.
She told the inquest she was going to write a report, urging that care home staff should be sufficiently trained to deal with such situations.
She said: “I want to see members of staff who come across these shocking scenes springing into action in accordance with training they have been given.”
Ms Tagliavini said: “It’s not a response I am unfamiliar with.
“It’s had many people react in this way. What does concern me is the fact these are trained members of staff in the nursing profession.”
She added that while cutting down Mr Li would not have made a difference in this case, it was “of great concern” that a lack of reaction by others in similar situations could possibly contribute to someone’s death in the future.
Hong Kong-born Mr Li had been admitted to the care home, run by the Four Seasons group, on the afternoon of February 25, 2012, upon his discharge from the West Middlesex Hospital.
His stay at the home was supposed to be temporary while more permanent accommodation was found, as Mr Li could no longer look after himself at home.
Daughter Beverley Owen said her father had suffered from ill health in the last years of his life, with blood pressure problems and anxiety.
“There was no indication in my mind he would do what he did,” she told the inquest.
She accompanied him to the care home, and said of her father’s mood: “He was subdued because he was somewhere new. He didn’t like the environment. He didn’t like the room because he felt it was smelly. Indeed, the sheets were a little bit dirty.”
Speaking after the hearing concluded, she described her father as an “effervescent” man and said her family saw the inquest as closure.
“I don’t think the care home could have prevented my dad from what he did,” she added.
A care home spokeswoman said the day after Mr Li’s death, the locks were changed so residents could not lock themselves in.
The Four Seasons group also has a new policy to deal with suicide prevention, the inquest heard.