'Lack of safeguarding' found after patient died

A "lack of safeguarding" was found in staff after a 24-year-old man absconded from a hospital and later died, a jury has ruled.

Christopher Nmaeka Arima-Egwuatu, who was an inpatient at The Discovery House in Lincoln, was found dead on 12 May 2023 at a property in Woad Farm Road in Boston, Lincolnshire.

Mr Arima-Egwuatu, who was diagnosed with autism spectrum disorder and paranoid schizophrenia, absconded to Boston on 11 May 2023 during an organised trip to a football match.

He died a day after as a result of taking heroin and cocaine.

On the last day of a four-day inquest at Myle Cross Centre in Lincoln, a summary was read out by area coroner Jayne Wilkes.

Mr Arima-Egwuatu first absconded on 27 April last year while out on hospital grounds on unescorted leave.

He returned to the ward that evening after spending about £300 on drugs.

Coroner Wilkes said Mr Arima-Egwuatu had been described by clinicians as "profoundly vulnerable" in the community and a "model patient".

On 11 May, Mr Arima-Egwuatu then attended an organised event at Lincoln City's ground on escorted leave.

The court heard he absconded again after sitting out the second half and making his way to an unlocked gate before leaving.

The inquest heard that Richard McGuiness, an occupational therapist accompanying Mr Arima-Egwuatu at the match, was "surprised at how fast Chris moved" and "gave no explanation" as to why he did not shout for him to come back.

'No attempt made'

Ms Wilkes said Mr Arima-Egwuatu got a taxi to a property in Woad Farm Road, Boston, and bought heroin and cocaine, which he shared with others and took himself.

The inquest heard other people in the property had "heard him snoring" in the morning of 12 May but he was then found dead in the evening and emergency services were called.

Paramedics arrived and he was pronounced dead just before midnight.

Mr Arima-Egwuatu had been reported to Lincolnshire Police as a missing person on the afternoon of 11 May by a mental health nurse from Lincolnshire Partnership Foundation Trust (LPFT).

The jury concluded that there had been "a lack of safeguarding demonstrated by the occupational therapists" at the Lincoln City ground.

It added that there had been "no attempt made to dissuade Chris from leaving".

Additional findings included information provided to Lincolnshire Police by the hospital after Mr Arima-Egwuatu had absconded as "out of date and inaccurate".

It also concluded that Julia Farmer, Mr Arima-Egwuatu's mum, "was not informed" that he had been granted escorted leave and there had been a failure in the "responsible clinician to review the decision to grant escorted leave".

Coroner Wilkes said consultant psychiatrist Jaswant Singh had said he had "taken into account Chris's regret and assurance that it wouldn't happen again" after he first absconded on 27 April.

Despite this, Coroner Wilkes said he had accepted he was "aware of Chris's cravings" and that he "didn't have contact with Julia Farmer" who had repeatedly requested to speak to him.

LPFT has been contacted for comment.

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