An NHS Trust has been criticised by a coroner after a patient escaped from a mental health hospital in south west London during a fire drill and took his own life.
Juan Martin was detained by police on April 6, 2022 at Beachy Head in Brighton after expressing a desire to self-harm.
He had previously been diagnosed with emotionally unstable personality disorder, depression and anxiety and had in the past attempted to take his own life.
Mr Martin was transferred to the Lotus Assessment Suite at Springfield Hospital in Tooting on April 7 and subsequently detained under the Mental Health Act, pending an appropriate bed.
On April 12, Mr Martin was seen by staff attempting to squeeze through a door leading to an exit but was challenged by staff, who persuaded him to return.
A bed became available at 3pm that day contingent on a patient transferring out of the hospital, but this did not happen, according to a Prevention of Future Deaths report issued by Priya Malhotra, assistant coroner for Inner West London.
At 7pm, the fire alarm at the unit was activated triggered by steam from a shower.
As the hospital had no fire evacuation policy for patients who were detained, Mr Martin was evacuated along with other patients to an “insecure” area outside the unit.
He “immediately ran off” and was seen on CCTV in the vicinity of the hospital for eight minutes after the evacuation.
Mr Martin withdrew £11.99 from a cash machine at 1.40am the following day.
Just before midday, local police officers were called to an incident at an unspecified location where Mr Martin was seen falling from a height.
Despite emergency life support provided by officers at the scene and paramedics, Mr Martin was pronounced dead at 12.36pm.
In the report, Ms Malhotra noted that Mr Martin had spent six days in the assessment suite without a suitable bed.
The Matron in acute and urgent care said that bed capacity is an “ongoing problem and has not been resolved”, citing one example where a patient waited for 7 days in A&E for a mental health bed.
They added that the “flow” of patients being discharged or moving to another setting “amplified the bed capacity issue”, the report said.
Ms Malhotra wrote: “Based on the evidence heard, my principal concern is that bed capacity in London remains inadequate. Whilst some action may have been taken by the Trust to better triage the need for beds it is insufficient to resolve the problem.
“It follows there is a genuine risk of future deaths directly connected to a shortage of mental health bed spaces in London unless further action is taken.”
The Trust must respond to the report by August 7.
A spokesperson for South West London and St George’s Mental Health NHS Trust told the Standard: “We are deeply sorry that our standards of care fell below those that we strive to achieve when this sad incident took place. Our thoughts are with the loved ones of JM at this difficult time.
“It is extremely important to ensure all our patients get the care they need as quickly as possible. We have been working hard to find new and better ways to do this, including with our partners across the South West London system, to develop a better system to make sure beds are quickly assigned to those patients who are most in need of our care.”
