Before HM Senior Coroner Andrew Walker
North London Coroner’s Court, 29 Wood Street, EN5 4BE

7 May – 13 May 2018
The jury into the death of Norman Dunwell has today concluded that his death in a North London mental health unit was contributed to by neglect. They highlighted failures in general care and management after staff failed to carry out five separate hourly observations. Norman, aged 49, died sometime between 11pm on 30 November 2017 and 5am on 1 December 2017. 
Norman is described by his family as being a kind hearted and loving man. He was detained under the Mental Health Act (s37/41) and resided on Fennel Ward, a medium secure unit, run by Barnet, Enfield and Haringey NHS mental health trust. He had been in the care of these services for over 10 years. At the time of his death, his discharge into supported accommodation in the community was being planned.
Norman had a history of using the synthetic drug, known as ‘Spice’. In August 2016, he collapsed on Fennel Ward, as result of smoking Spice in the early hours of the morning. On this occasion, hourly observations were undertaken. He was provided with emergency medical care and taken to Barnet General Hospital, where he recovered.
On 28 November 2017, Norman returned from unescorted community leave. He appeared to his named nurse to be under the influence of drugs and his leave was rescinded. Despite this, he was not subject to a body search, nor was his bedroom searched, to establish if he had brought any illicit substances back into the ward. Evidence was heard that Norman was last observed in bed at 10.56pm on 30 November.
Despite Norman being on hourly observations in accordance with Trust policy, the staff failed to carry these out during the night. When he was next checked on at 5:11am hours he was collapsed on the floor of his bedroom, deceased. The paramedics from the London Ambulance Service were of the view that Norman had probably been dead for a few hours. The initial response from staff on duty was that he was seen alive, sitting up in a chair at 3am, yet CCTV footage showed no one had checked on him during this period.
The inquest heard there were three staff on duty, two of whom admitted to having fallen asleep at different times. The records between midnight to 4am were falsified in relation to all 14 patients. The Trust admitted the failure to carry out observations and admitted that staff breaks were not managed by the nurse in charge.
Yvonne Dunwell, sister of Norman said: Norman was a kind hearted and loving man, with a happy go lucky personality, charming, jovial, considerate to others, and believed in the rights of his fellow friends, with strong leadership, qualities. I am relieved that the jury has recognised the Trust’s complete failure to carry out observations on Norman for five hours resulting in him being left to die in a wholly undignified way. Even though we know from the toxicology report that Norman took Spice, the hospital still has a duty to protect its patients and do all they can to protect life.” 
Natasha Thompson, caseworker at INQUEST, said: “This inquest has uncovered serious failings, lies and neglect by staff who had a duty of care to Norman. It is essential that key witnesses exercise candour to ensure a full and fair hearing, and to uncover any failings within the case. Without this, inquests are unable to perform their vital role.

Without the CCTV evidence, such failings of neglect may never have come to light. This case reinforces the need for increased pre-inquest scrutiny for deaths in mental health settings through independent investigations.”
Fleur Hallett of MW Solicitors said: “It is shocking that in a medium secure unit, which caters for the most vulnerable individuals, health care assistants were asleep when they ought to have been carrying out crucial hourly observations, and the nurse in charge did not notice. Even when hospital staff (one of whom had been dismissed for gross misconduct) gave evidence at the inquest they continued to minimise their failings, despite the CCTV evidence."



For further information, please contact Lucy McKay and Sarah Uncles on 020 7263 1111 or [email protected] [email protected]

INQUEST has worked with the family of Norman Dunwell since December 2017. The family is represented by INQUEST Lawyers Group members Fleur Hallett of MW Solicitors and Counsel Maya Sikand of Garden Court Chambers, London.

Other Interested Persons represented at the inquest were Barnet, Enfield and Haringey NHS Mental Health Trust and a healthcare assistant on the Fennel Ward.