Henok Gebrsslasie: Prevention of Future Deaths Report
Hospital Death (Clinical Procedures and medical management) related deathsMental Health related deathsSuicide (from 2015)
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Date of report: 06/03/2025
Ref: 2025-0124
Deceased name: Henok Gebrsslasie
Coroners name: Delroy Henry
Coroners Area: Coventry
Category: Hospital Death (Clinical Procedures and medical management) related deaths | Mental Health related deaths | Suicide (from 2015)
This report is being sent to: Coventry and Warwickshire Partnership NHS Trust
| Regulation 28: Prevention of Future Deaths Report | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. [REDACTED], Chair of the Coventry and Warwickshire Partnership NHS Trust 2. [REDACTED], Chief Executive at Coventry and Warwickshire Partnership NHS Trust 3. [REDACTED], Estates and facilities management consultant/director at Coventry and Warwickshire Partnership NHS Trust | |
| 1 | CORONER I am: Delroy Henry, Area Coroner, Coventry. Coventry Coroners Office, The Register Office, Manor House Drive, Coventry, CV1 2ND |
| 2 | CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, Schedule 5, paragraph 7 and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. |
| 3 | INVESTIGATION and INQUEST On 13th August 2021 I commenced an investigation into the death of Henok Zaid GEBRSSLASIE (aged 23 years). The investigation concluded at the end the inquest on 5th March 2025 at Coventry Coroners Court. The conclusion of the death of Mr GEBRSSLASIE was that death was “suicide and a narrative” a copy of which I attach to this report. |
| 4 | CIRCUMSTANCES OF THE DEATH Mr GEBRSSLASIE on the 2nd August 2021 was arrested by the police having been removed from a bus in possession of a plank of wood and oddly offering the police money sufficient for bus fare, this and his behaviour , throwing a road sign at officers precipitated his detention in police custody which gave rise to a mental health act assessment and his detention at the Caludon Centre. Part of his medical treatment included antipsychotic medication and sedation following an episode of violence. On 5th August 2021 Mr GEBRSSLASIE absconded from the Caludon Centre via a window, however he was located at his home address and returned to the Caludon Centre the next day and remained detained (under the Menal Health Act) on the Sherbourne Ward, the Psychiatric Intensive Care Unit, his behaviour leading staff to provide him with rip-proof clothing. There was an issue with language, involved communications achieved with an interpreter. Over the following days, in the context of medications provided, his mood was now adjudged seemingly more stable and by the 12th August 2021 Mr GEBRSSLASIE was allowed his own clothing, rip proof clothing removed. Mr GEBRSSLASIE was provide some hospital type pyjamas whist his personal clothing was being washed. Mr GEBRSSLASIE was on level 2 observations (every 15 minutes) and having expression a wish to go home it was communicated to him that his discharge from hospital was an ongoing process and not imminent. On 12th August 2021, the body of Mr GEBRSSLASIE was discovered in his bedroom (Bedroom 2) on Sherbourne Ward nearly 3 hours after his last observation. The deceased had a ligature ([REDACTED]) around his neck and was partially suspended from the bedroom door. The Oxevision system camera (part of a research project, to assess whether new non-contact monitoring technology improves quality of care and safety for patients and staff) in the patients’ rooms captured the last interactions Mr GEBRSSLASIE has with staff, where upon moments after the bedroom door closed Mr GEBRSSLASIE then proceeded to use the same bedroom door as an anchor point for the ligature. |
| 5 | CORONER’S CONCERNS During the inquest, the evidence and information revealed matters giving rise to a 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 them to you. The MATTER(S) OF CONCERN are as follows: i. The inquest explored issues such ligature anchor points. ii. It is known (and has been known for some years by the Coventry and Warwickshire Partnership NHS Trust) that the top of a door is a “high risk area” for ligatures in particular patients bedroom which have doors that may be locked by patients from the inside and thereby an unobserved patient area. iii. The circumstances of this inquest touching upon the death of Henok GEBRSSLASIE in August 2021 accentuated this point. iv. Such risks carrying with it a clear risk of death. v. Since the incident it was known that door top alarms is “the way forward” as an environmental change that would mitigate such risk and referred to in a serious investigation report in April 2023, this “way forward” expressed in evidence during the inquest. vi. There remains (now 42 months post Mr GEBRSSLASIEs death) no door top alarms on the patient bedroom doors at Sherbourne Ward, the Psychiatric Intensive Care Unit, at the Caludon Centre. vii. The cumulative effect (there ‘seemingly’ no expediency to physically better mitigate this known environmental high-risk issue) is such that a concern as to future deaths exists as of March 2025. |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1st May 2025. 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the following: 1. The family of Henok Zaid GEBRSSLASIE. 2. Her Honour Judge Alexia Durran the Chief Coroner of England & Wales Chief Coroner’s Office, 11th Floor Thomas More, Royal Courts of Justice, Strand, London, WC2A 2LL. chiefcoronersoffice@judiciary.gsi.gov.uk 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. She may send a copy of this report to any person who she 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. |
| 9 | Date: 6th March 2025 |