Jagjeet Singh: Prevention of Future Deaths Report
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Date of report: 04/11/2024
Ref: 2024-0606
Deceased name: Jagjeet Singh
Coroners name: Melanie Lee
Coroners Area: Inner North London
Category: Alcohol, drug and medication related deaths
This report is being sent to: NHS England | Department of Health and Social Care
| Regulation 28: Prevention of Future Deaths report | |
|---|---|
 THIS REPORT IS BEING SENT TO:1. Secretary of State for Health and Social Care, Department of Health and Social Care 2. Chief Executive, NHS England | |
| 1 | CORONER I am: Melanie Sarah Lee Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP |
| 2 | CORONER’S LEGAL POWERS 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. |
| 3 | INVESTIGATION and INQUEST On 18 March 2024 an investigation was commenced into the death of Jagjeet Singh (age 52 years). The investigation concluded at the end of the inquest on 29 October 2024. The medical cause of death was 1a. acute respiratory depression, 1b. fatal morphine and methadone toxicity, 2. emphysema and bronchopneumonia. The conclusion at inquest was drug related. |
| 4 | CIRCUMSTANCES OF THE DEATH Jagjeet Singh had a long history of intravenous substance misuse, associated physical health problems and a mental health diagnosis of EUPD. He spent long and numerous periods in hospital for his physical health, self-harm and suicide attempts, drug overdoses and as a mental health patient. Between 20 August 2023 and 6 March 2024 he was an inpatient on a mental health ward but spent periods on medical wards. Following his discharge from hospital, on 7 March 2024 Mr Singh went to Mr Singh’s home were they drank beer together and Mr Singh injected heroin. Mr Singh was alive when his friend left the property that evening but when he returned the following day, Mr Singh was deceased on the kitchen floor with a syringe next to him. |
| 5 | CORONER’S CONCERNS 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 Singh was an inpatient on a mental health ward at the Homerton Hospital from 20 August 2023 until 6 March 2024, initially under s.2 of the Mental Health Act and then as an informal patient. On three occasions he spent time on medical wards for infected leg ulcers, arising from his IV drug use. During these periods his mental health bed was, understandably, allocated to other patients. However, on discharge from the medical ward, there was no mental health bed available for him and he either went home or, as his property was uninhabitable for a period of time, was accommodated in a Travel Lodge at the cost of the Trust, returning to the mental health ward for meals and medication. Mr Singh did not like the Travel Lodge and on one occasion was evicted. He therefore slept on a coach in the mental health ward and appears to have spent at least one night sleeping rough. I heard that a bed on the mental health ward should have been available for Mr Singh when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally. It was described to me as a crisis. |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you and/or your organisation 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 30 December 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the following. [REDACTED] [REDACTED], 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. |
| 9 | DATE 4 November 2024 SIGNED BY ASSISTANT CORONER |