Emmanuel Ladapo: Prevention of future deaths report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 23/04/2024

Ref: 2024-0215

Deceased name: Emmanuel Ladapo

Coroner name: Mary Hassell

Coroner Area: Inner North London

Category: Hospital Death (Clinical Procedures and medical management) related deaths

This report is being sent to: Camden and Islington NHS Foundation Trust

Regulation 28: Prevention of Future Deaths report
1. [REDACTED] Chief Executive Camden & Islington NHS Foundation Trust (C&I) 4th Floor, East Wing St Pancras Hospital 4 St Pancras Way London NW1 0PE
I am:   Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP
I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29.
On 13 March 2023 one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Emmanuel Ladapo aged 24 years. The investigation concluded at the end of the inquest yesterday. I made a determination at inquest of death by suicide. I recorded a medical cause of death of: 1a asphyxiation via plastic bag and inhalation of nitrogen gas.
Mr Ladapo had been diagnosed with paranoid schizophrenia and depression. He had undergone several hospital admissions, had been treated by the Camden & Islington (C&I) early intervention service and was at the time of his death being treated by one of the C&I rehabilitation & recovery teams.
During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows.
Mr Ladapo lived with his sister, who wanted very much to be involved with his care. However, I did not hear any evidence of engagement with her by C&I, either:
generally, during his time with the early intervention service or the rehabilitation & recovery team; or
when in April 2022 he was found to have ordered a bolt gun on the internet that was only intercepted because it was discovered by the delivery driver; or
on transfer from the early intervention service to the rehabilitation & recovery team in June 2022.
Lack of engagement with families is a story that I have heard often in inquests, and was the subject of prevention of future deaths reports that I sent to you on:
04.03.21 regarding Grazyna Walczak; and
17.03.21 regarding Ben O’Hara; and to your predecessor on:
11.01.16 regarding Efstratios Voukelatos; and
29.04.15 regarding Finnulla Martin.
Mr Ladapo was noted to have deteriorated by the time of his consultation on 19 January 2023, and he was still depressed on 16 February 2023, but the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal.
This was the error of an individual, but it too is an omission that I have observed and written to C&I about before. Furthermore, the initial management review did not identify the omission.

I am concerned that the importance of exploring the suicide question does not feature highly enough in the consciousness of C&I staff.
In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 June 2024. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
I have sent a copy of my report to the following.
[REDACTED], sister of Emmanuel Ladapo
Care Quality Commission for England
HHJ Thomas Teague QC, the Chief Coroner of England & Wales
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.