14 June  2023

Before HM Assistant Coroner Edwin Buckett
Poplar Coroner’s Court
15-19 May 2023

Billy Guedalla, 46, was found dead on 30 October 2021 after taking their own life at home having wrongly been allowed to leave Gardner Ward, Homerton Hospital the day before. Now a Coroner has issued a Prevention of Future Deaths report following concerns over short-staffing risks to patient safety.

Billy’s family were not made aware that Billy was missing until they arrived for a visit at the hospital at 2pm on 30 October. It was left to them to make the 999 call that led to the discovery of Billy's body.

Billy was much loved by their parents, siblings, nieces, nephew and many friends. They were described by their family as “intelligent, articulate, perceptive and empathetic” and committed from a young age to making a difference for the better in the world.

Billy undertook nursing training, volunteered for the Campaign Against the Arms Trade, served as a legal observer on numerous protest demonstrations and during the London 2011 riots, and was a support volunteer for defendants at court. Billy became active in LBGTQ+ and other issues often considered marginal or controversial.

Billy had longstanding mental ill-health that resulted in a number of inpatient hospital admissions since 2013. Their penultimate admission was from 1-11 October 2021. They were admitted to Homerton’s Gardner Ward again on 26 October in crisis., seeking help to prevent them from taking their own life.

The inquest evidence identified a host of serious failings in Billy’s care. Staff did not comply with the patient admission policy, important records were not updated, and vital risk information disclosed during a ward round on 28 October was not shared with staff or properly recorded. Further, the plan to keep Billy safe, that relied on 1:1 support, failed to recognise that this could not be achieved because of acute staff shortages on the ward.

On 29 October, following a call from a friend raising concerns, a decision was made not to allow Billy to leave the ward unescorted. This crucial decision was not communicated to staff, in part because of management failings to ensure adequate staffing on the ward. Numerous witnesses indicated that this short staffing routinely compromised patient safety.

Shortly after 6pm on 29 October, a health care assistant wrongly allowed Billy to leave alone to get some fresh air. That was despite Billy’s high risk of suicide and the clinical decision that Billy must not be allowed to leave the ward for their own safety. Billy did not return.

Outgoing day staff did not raise any concern or handover to the incoming night staff that Billy was missing. Billy’s absence was not discovered until 8pm, around two hours after they left. At 00.36am on 30 October staff called Billy’s mother but did not leave a message.

At 02.10am staff contacted the police but completely failed to state the urgent and serious suicide risk in the case. Staff were advised by police to call an ambulance but did not do so.

Instead, they called the police again at 02.36am and were again told to call an ambulance, but then waited over 12 hours before doing so, only after Billy’s family had raised the alarm and called the police themselves.

On the final day of the inquest, the NHS Trust responsible for Homerton – ELFT – admitted that there were numerous failings in Billy’s care because staffing levels on the ward were not adequate to deal with patient need. This was contrary to their own Serious Incident Review which had found staffing to be adequate after Billy’s family raised specific concerns about this issue.

The Coroner identified a long list of failings in Billy’s care, including that:

  • Billy should not have been permitted to leave the ward alone.
  • The decision that Billy should not be permitted unescorted leave was not communicated to all staff members on the ward. This was a serious failure which directly caused or contributed to Billy’s death.
  • The assessment made before Billy was allowed to leave the ward was inadequate.
  • There was a complete failure to appreciate the urgency of locating Billy and to follow the hospital policy which applied to missing patients.
  • Staff failed to properly contact Billy’s family and friends or leave messages which could have enabled Billy to be located.
  • Night shift staff took far too long to contact the emergency services.
  • Staffing levels on both the 29th and 30th October 2021 were not adequate and this contributed to the failings set out above.

The inquest heard that, alarmingly, little has changed since Billy’s death. The Coroner sent a Report to Prevent Future Deaths to the Chief Executive of ELFT on 8 June. This listed 10 matters of concern including that short-staffing on the unit affected the care provided to Billy, the assessment of them and record keeping. The Trust must now respond by 4 August 2023.

Vicky Guedalla, Billy’s mother said on behalf of Billy’s family: “The inquest is over. Billy is still dead. The condolences of the Trust so far are empty words that do nothing to soothe our sore hearts. It’ll take deeds not just words to do something about the dangerous understaffing that led to Billy’s death. Please, ELFT, be urgently pro-active now for the sake of your overworked staff and to protect your vulnerable patients now and in the future.  You’ve dragged your feet so far, but you have the chance to take the Coroner’s PFD report as a wakeup call to do battle for adequate resources. Please don’t let us down.”

Jo Eggleton of Deighton Pierce Glynn solicitors, said: “Once again it has taken the tenacity of a bereaved family to uncover the truth of the failings that led to their loved one’s death. Instead of focusing on identifying what went wrong and learning lessons the Trust and their solicitors have consistently tried to limit public scrutiny of their actions, including repeatedly ignoring Coroner’s directions and telling at least one witness to remove relevant evidence from their statement.”

Selen Cavcav, Senior Caseworker at INQUEST, said: “What happened to Billy should have never happened. Those responsible for running the unit ought to have known that their staffing levels were dangerously low, and their risk assessment systems were completely unreliable to keep vulnerable patients safe. Empty platitudes do not save lives. Now is the time to take urgent action to address the failures so clearly spelled out by the coroner at this inquest.”

For further information please contact Leila Hagmann on [email protected].

Billy’s family are represented by INQUEST Lawyers Group members Jo Eggleton of Deighton Pierce Glynn solicitors and Jesse Nicholls of Matrix Chambers. They are supported by INQUEST Senior Caseworker Selen Cavcav.

Other Interested Persons represented include East London NHS Foundation Trust (ELFT) and the Metropolitan Police.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.