Lack of ward supervision led to asylum seeker's death

An inquest has concluded that a lack of supervision on an intensive care mental health ward, where a man died, meant policy and procedures weren't adhered to.

Henok Zaid Gebrsslasie took his own life at the Caludon Centre, Coventry, on 12 August 2021.

He should have been checked every 15 minutes but was left unobserved for three hours, the court heard.

The NHS Trust which runs the facility said it had "fallen short" on the patient's care and issued an unreserved apology.

Insufficient actions and observations carried out by a student nurse also contributed to his death, jurors said.

Therapeutic observations on the patient by other staff were also inadequate, they concluded.

The Coventry coroner inquest heard two healthcare workers falsified paperwork to make it look as though the checks on the patient had been carried out.

The last member of staff to check on Mr Gebrsslasie, student nurse Amy Edwards, told the court that she had been sent to his room to take his blood pressure and temperature at about 13:55 BST.

Observing him from the doorway she said he had told her to "go away and leave him alone," the court heard.

"He also said he wanted to be left to sleep forever," she said.

Video footage of the interaction played in court showed the 23-year-old patient sitting on the floor on the opposite side of his bed to where Ms Edwards was standing.

Mr Gebrsslasie died shortly after 14:00, the inquest was told.

He was found unresponsive in his room shortly after 17:00.

One healthcare worker, who failed to check on him on the afternoon of his death, said she had a "habit" of rewriting observation notes "to get out of a situation".

Another said she had "made a mistake", with a third healthcare assistant claiming he was directed to falsify notes by a more senior member of staff.

The football-loving youngster was kind, liked to make jokes and help the needy, his family told the inquest hearing via a statement.

Originally from Eritrea, he had arrived in the UK in May 2020 after travelling across the Sahara, Mediterranean and Europe.

Coventry and Warwickshire Partnership NHS Trust facility which runs the centre said it was "committed to addressing the concerns identified during our own internal investigation" into the death.

It had also made improvements to operating procedures and reduced environmental risks on its wards.

"We offer our deepest sympathy to Mr Henok Gebrsslasie's family and loved ones," it added.

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