10 December 2021

This media release is by Doughty St Chambers, reposted for reference

Before Assistant Coroner Caroline Topping
Surrey Coroner's Court
24 November - 9 December 2021

Philip Lamplough, known as Phil, died on 17 April 2020 at St Peter's Hospital. He was 53 years old and had been a mental health inpatient at the Abraham Cowley Unit (ACU) between 13 and 15 April 2020. Phil died of a hypoxic brain injury caused by hanging, following a fatal attempt on his own life on Clare Ward at the ACU on 15 April 2020.


The jury heard evidence that Phil was admitted to the ACU under the Mental Health Act on 13 April 2020 after a period of significant decline in his mental health in the weeks leading up to his death. He was assessed by psychiatric liaison at East Surrey Hospital on 3 April after taking an overdose, and at Royal Surrey County Hospital on 11 April after contacting 111 and asking to be sectioned due to suicidal thoughts. He was discharged on both occasions with no further mental health intervention. Although Phil was being treated in the community by the substance misuse services of Surrey and Borders Partnership Trust, there was no referral made for him to receive mental health treatment in the community. After being discharged on 11 April, Phil self-harmed at his accommodation and was attended to by ambulance and police.

On the morning of the 12 April he was taken to a homeless shelter by the police and staff there later called both the police and ambulance due to concerns about Phil’s mental health. In the early evening of 12 April Phil was sectioned by the police under section 136 of the Mental Health Act because he was thought to pose a risk to himself. A Mental Health Act assessment was carried out and it was decided that Phil should be detained for a period of further assessment.

In the opinion of the expert psychiatrist instructed by the Coroner, Dr Rao, Phil was suffering from a relapse of a psychotic condition and the symptoms of methadone withdrawal, but these matters were not adequately explored or monitored when he was admitted to the ACU.

Jury conclusions

After hearing nine days of evidence, the jury concluded that Phil died by suicide, and that his death was contributed to by neglect. The following factors were found to have probably made a material contribution to Phil’s death:

  • Failure to undertake a specific risk assessment and create a treatment plan to deal with the risk of methadone withdrawal and the need to monitor for withdrawal symptoms.
  • Failure to assess Phil for methadone withdrawal using an opiate withdrawal scale 4 times a day to monitor for withdrawal signs.
  • Failure to ensure that the SBARS (the risk assessment tool) contained specific reference to the need to observe Phil for methadone withdrawal.
  • Failure to follow the observation policy and record adequate information in the observation log in relation to methadone withdrawal.
  • Failure to act expeditiously or effectively when Phil repeatedly sought a review of his medication in general and in particular on the 15th April 2020 in relation to Subutex.
  • A lack of staff training about methadone withdrawal and dual diagnosis patients
  • Failure to undertake an adequate risk assessment and record a care plan to assess and manage Phil’s psychotic symptoms after the ward round on the 14th April 2020.
  • Failure to ensure that the SBARs made specific reference to the need to observe Phil for psychotic symptoms.
  • Failure to follow the observation policy and record adequate information in the observation log in relation to psychotic symptoms.
  • Failure to escalate the psychotic presentation observed by a member of staff on the 15th April 2020.
  • Failure to engage sufficiently with Phil on a one-to-one basis to ensure that his needs were met and he felt reassured that his mental health and withdrawal symptoms would be addressed.
  • A lack of staff training around the taking and recording of observations.
  • A lack of time available to carry out observations.
  • The unintentional creation of a ligature point by the cutting down of the door stop in 2018.

The following further factors were also found to have possibly made a material contribution to Phil’s death:

  • Failure to take advice from I access (substance misuse service) as a matter of urgency when Phil refused to continue to take methadone no later than the 14th April 2020.
  • Failure to provide Phil with adequate mental health support by psychiatric liaison on either, or both, of the 3rd April 2020 or the 11th April 2020.
  • Failure to provide adequate staffing to meet Phil’s needs on the ward.

Jazz Ahwan, on behalf of Phil's son said: "It is tragic to hear about the appalling failures that contributed to Phil’s death. Because of them, my son no longer has the chance to reconcile with his dad and Phil has been lost to the rest of his family. I am grateful to the Coroner for conducting such a thorough investigation into what happened. I hope that the ACU will learn from these mistakes and improve their systems to ensure that this never happens to anyone else."

Elaine Macdonald of Tuckers Solicitors said: "The evidence in this case has again highlighted serious failings at the ACU. Surrey and Borders Partnership Trust need to take action to address the greatly concerning issues identified in Phil’s case."


For more information, photographs, and to note your interest contact Lucy McKay on [email protected]or 020 7263 1111

The family is represented by Inquest lawyers group members Elaine Macdonald of Tuckers Solicitors and Matthew Turner of Doughty Street Chambers.

The other Interested Persons at the inquest were Surrey and Borders Partnership Trust, Surrey County Council, and SECAmb.

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