Warning: Contains distressing content
A suicidal man died hours after NHS staff separated him from his mother and then allowed him to wander out of hospital.
Paz Ogbe-Millar, 30, was taken to Watford General Hospital after self-harming at home, and was referred to mental health services after being assessed as a “moderate” risk to himself.
Despite his vulnerable state, Mr Ogbe-Millar’s mother was ejected from the emergency department where he was waiting for the mental health team.
After being left alone he was given permission by medics to go outside for a cigarette and never returned.
Later that day, December 2, 2021, Mr Ogbe-Millar took his own life near Harrow and Wealdstone station in northwest London.
North London Coroner Tony Murphy has issued a Prevention of Future Deaths report after airing concerns at the inquest in October 2022 about levels of monitoring of mental health patients at the hospital.
He found that they have not yet been addressed.
The inquest was told Mr Ogbe-Millar was a heavy cannabis user, and needed two bouts of hospital treatment for psychosis in 2020 and early 2021.
He relapsed into drug use in November 2021, and his worried mother referred him for mental health assistance. But he was discharged from the team’s care on November 30, 2021.
In the early hours of December 2, Mr Ogbe-Millar sent a message to his mother saying: “I’m sorry for my actions and I hope you all find peace”, and he was rushed to hospital after being found at home by police.
“There was an inadequate system for recording the information provided by the police to the hospital concerning his risk of self harm,” the coroner said.
“Mr Ogbe-Millar was assessed by hospital staff later that morning as a moderate risk of self-harm and told to await the arrival of the local Mental Health Liaison Team, which is operated by the Hertfordshire Partnership University NHS Foundation Trust.
“Despite Mr Ogbe-Millar’s risk of self-harm and the protective factor provided by the presence of his mother, she was not allowed to stay with him at the emergency department while he waited for the Mental Health Liaison Team.
“Instead, she was required to leave, by staff in breach of hospital policy.
“The Mental Health Liaison Team had not arrived to assess Mr Ogbe-Millar by the time his mother was required to leave the hospital due to problems surrounding the referral system.
“Soon after his mother had been required to leave, Mr Ogbe-Millar left the Emergency Department unaccompanied saying he was going outside to smoke a cigarette. He never returned.”
The coroner heard evidence of “confusion” about the appropriate levels of monitoring of mental health patients in A&E, and a “lack of clarity” on the trust’s procedures.
A West Hertfordshire Hospitals NHS Trust spokesperson said: “We are reviewing the coroner’s comments in the prevention of future deaths report and the actions that need to be taken. We will respond in full by the 2 April deadline.
“Our sympathies are with Mr Ogbe-Millar’s family and we are keen to learn from the coroner’s review to improve our systems and processes.”
