Watford General Hospital must act following suicide death

A coroner has called on a hospital to act after a mental health patient walked out alone and took his own life.

Paz Ogbe-Millar, 30, died near Harrow and Wealdstone Station in December 2021 after leaving Watford General Hospital.

A prevention of future deaths report (PFDR) revealed Mr Ogbe-Millar may not have been "subjected to an appropriate level of observation".

West Hertfordshire Teaching Hospitals NHS Trust said it was "reviewing the coroner's comments".

The report, compiled by North London coroner, Tony Murphy, revealed Mr Ogbe-Millar left the hospital unaccompanied after suffering a mental health-related emergency.

It revealed that trust staff may not have followed so-called Standard Operating Procedures, which set out patients at moderate risk of self-harm, like Mr Ogbe-Millar, should be under continuous observation.

Mr Ogbe-Millar - described in the report as an "articulate, charming and well-read" young man - was diagnosed with cannabis-induced psychosis in 2020 and had received treatment from community and in-patient mental health teams at various stages.

After leaving hospital in March 2021, he was discharged from the community mental health team the following June, but resumed using cannabis in the November, leading to a relapse of his mental illness.

His mother had sought help from the community mental health team, but he was discharged in the same month after they referred him to an organisation which did not specialise in psychosis.

The report said that in the early hours of 2 December, Mr Ogbe-Millar sent a text message to his mother saying "I'm sorry for my actions and I hope you all find peace".

Police took him to the emergency department at Watford General where there was an "inadequate system for recording the information provided by the police to the hospital concerning his risk of self-harm", the report added.

"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," the PDFR said.

"She was required to leave by staff in breach of hospital policy."

Shortly afterwards, Mr Ogbe-Millar said he was leaving hospital to smoke a cigarette, but staff did not accompany him.

He died later the same day.

The report said the trust's emergency department Adult Mental Health Pro Forma demanded that staff "consider 15-minute special observations" for medium-risk patients.

Coroner Mr Murphy said: "My concern is that the inconsistency between these two documents creates a risk that mental health patients at medium risk of self-harm awaiting assessment for their mental health condition in the emergency department may not be subjected to an appropriate level of observation."

A 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."

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