19 July 2019

Before HM Senior Coroner Andrew Harris
Southwark Coroner’s Court
4 to 18 July 2019

The inquest into the death of Kenan Canalp has concluded, finding that neglect and serious failures by South London and Maudsley NHS Foundation Trust (SLaM) contributed to his suicide - and that inadequate levels of observation caused his death. Kenan was 27 years old when he died whilst detained in the Maudsley Hospital in Camberwell in the early hours of 8 March 2018.

Kenan was born in Famagusta, Northern Cyprus to a Turkish Cypriot father and British mother. His family describe him as a truly inspiring person who will be missed dreadfully. 

On 5 March 2018, Kenan was admitted from King’s College Hospital A&E to the Maudsley ‘place of safety’ (under section 136 of the Mental Health Act) following an attempt to end his life. After a delay due to a shortage of beds, he was detained for assessment (under Section 2, MHA) and transferred to ES2 Ward on 8 March 2018. Eight hours later at 11.53pm Kenan was found unresponsive. The jury found that Kenan should have been on 1:1 observations at this time, meaning that a Registered Mental Health Nurse should have been with him at all times. Instead, Kenan was placed on general observations, requiring only hourly checks. General observations are the lowest level of observations permitted on a psychiatric ward.  

After hearing eight days of evidence, the inquest jury concluded that Kenan’s death was suicide, caused by fatal pressure to the neck, self-suspension, and inadequate levels of observation. In a narrative conclusion, they found that a failure to place Kenan on 1:1 observations on ES2 ward contributed to his death. They found this amounted to neglect because it was a failing of basic care and a “gross failure due to serious risk of suicide”. SLaM admitted this failure during the inquest, stating that the whole of the risk assessment should have been reviewed as part of the decision regarding his level of observations on ES2 ward in particular. Some of the nurses caring for Kenan were unaware he had been admitted to hospital because of an attempt on his own life, and so were unaware of Kenan’s suicide risk.

At around 8pm on 7 March 2018, a red mark around Kenan’s neck was noticed by staff. Staff told the inquest that they did not assess Kenan for suicidal thoughts or intention because they were scared of provoking aggression on the ward. Although Kenan had not been violent towards any staff, their approach had been affected by a number of recent assaults on staff by other patients.

During the course of the inquest SLaM admitted that they failed Kenan after seeing the red mark by not undertaking a fuller clinical review at this point, including consideration of observation levels, or conducting a formal handover to the oncoming night shift staff. The inquest jury concluded that this failure again amounted to neglect, due to Kenan’s previous self-harm and suicide risk.

The jury also found the following failures more than minimally contributed to Kenan’s death:

  • The handover of information between place of safety and ES2 ward, which was not adequate enough due to the risks.
  • The quality of risk assessments made on both wards, which lacked detail. A senior doctor should have been contacted to review Kenan’s management plan when he was admitted to the ward; a failure which SLaM also admitted.
  • The handover of information from the late shift to the night shift on ES2 ward, which had insufficient details relating to his suicidality, i.e. the red mark on his neck.
  • The staff’s preoccupation with Kenan’s potential risk of violence led to less consideration of his suicide risk.

The jury further found that the failure to contact Kenan’s family to ascertain information about his risk of suicide possibly contributed to Kenan’s death. The jury also concluded that all staff should be competent in the use of this electronic record system (known as EPJS), and that this failure contributed to his death. They further commented that training and consistency seemed to be a major factor in some of the failings at various points during Kenan’s care.

Following the jury’s conclusion, Senior Coroner Andrew Harris requested that the family’s lawyers send him submissions on Prevention of Future deaths by 25 July 2019. The Trust will then have seven days to respond. On consideration of these submissions the Senior Coroner will decide whether to make a Prevention of Future Deaths Report, with the aim of addressing any continued risks.

Anne Mosley, Kenan’s mother said:Kenan was a gift and an education to me as his mother. He was a truly inspiring person. We all miss Kenan dreadfully. I wish he was still here. Kenan was in a crisis neither he nor we could stop. This crashed into the crisis of frontline NHS mental health care. We all think it only happens to others, but this loss could happen to anyone. I hope that the outcome of this inquest is that no other family loses a loved one at the Maudsley.”

“The inquest process has been both painful and cathartic. I would like to thank Senior Coroner Andrew Harris for his very careful and thorough inquiry into Kenan’s death. The inquest process has allowed us, as a family, to finally understand how it was that Kenan was able to take his own life whilst under section on an acute psychiatric ward. I would also like to thank INQUEST for all of their support, particularly in explaining the legal aid process and assisting me to instruct a legal team.”

The family’s solicitor, Claire Macmaster of Simpson Millar, said: Owing to a catalogue of errors in his care Kenan was able to take his own life only eight hours after admission to ward ES2. These errors included basic tasks around risk assessments and care planning either not being undertaken or being of poor quality. The sad fact is that Kenan’s death could have been prevented had basic processes been followed and if management had ensured that the staff on the ward were well-trained, competent and supported to carry out their roles.”

Anita Sharma, Senior Caseworker at INQUEST who worked with the family, said: “Kenan was completely dependent on mental health professionals but neglect and basic failures by SLaM resulted in his death. This is not an isolated incident involving this NHS Trust. Whilst we welcome their admission of multiple failures at the inquest, the real test lies in the implementation of changes across SLaM mental health services.”

Layla Allen, a close family friend said: “When Kenan was admitted to Maudsley, the family were extremely relieved believing that he was now in a safe place and would get the care he desperately needed. However, due to neglect Kenan lost his life and his family lost everything. Nothing can even begin to fix the devastation caused. The Trust has made some admissions of failures and has stated that new procedures are being encouraged and developed on ward ES2. Nevertheless, if the procedures in place at the time of Kenan’s death had been followed he would not have died. The sole way to prevent a repeat of this tragedy is for management to ensure all staff are well-trained, competent and supported.”



For further information please contact INQUEST Communications Team on 020 7263 1111 or email Lucy.

To share this press release on social media see the INQUEST webpage.

INQUEST Senior Caseworker Anita Sharma has been working with Kenan’s family since March 2018. The family are represented by INQUEST Lawyers Group members Claire Macmaster and Christopher Callender of Simpson Millar solicitors, and Rachel Barrett of Cloisters Chambers.

For further information regarding Simpson Millar or interview requests please contact:

Caroline Woffenden on 011 42 756 784 or [email protected]

Other Interested persons represented were South London and Maudsley NHS Foundation Trust.

Please refer to the Samaritans Media Guidelines for reporting on suicide and self-harm. 

South London and Maudsley NHS Foundation Trust:

South London and Maudsley NHS Trust provide mental health services for people in South London, including the Maudsley Hospital in Camberwell, the Ladywell Unit in Lewisham Hospital, and Bethlem Royal Hospital in Croydon.

Numerous inquests on deaths in their mental health facilities in recent years have highlighted failures and, in some cases, neglect.

  • Agnes McDonald, 41, walked out of the Ladywell mental health unit run by SLaM and died when she was struck by a train.  She had been admitted to the Unit as a non-sectioned patient just three weeks before her death. An inquest in January 2019 found that Agnes took her life while on approved leave.
  • Catherine Horton, 48, was an inpatient in SLaM run Bethlem Royal Hospital when died on 24 July 2017. An inquest in December 2018 concluded that she died from suicide, contributed to by neglect on the part of the medical and nursing team responsible for her care.
  • Katy Roberts, 16, was in the care of SLaM Children and Adolescent Mental Health services in when she died a self-inflicted death in October 2017. An inquest highlighted failures in care planning and communication in April 2018.
  • Rosie Flett, 21, was a detained inpatient also on Gresham 1 Ward Bethlem Royal Hospital run by SLaM when she died on 11 February 2017. The inquest found searches and observations were not effective in locating blades used for self-harm, despite five previous incidents of cutting. The coroner wrote a Prevention of Future Deaths report in May 2018.
  • A.H., 27, was a detained inpatient at Bethlem Royal Hospital when she was on unescorted leave and died on 18 August 2016. The inquest in May 2017 found failings in the hospital’s recording and updating of risk assessment, and that adequate steps were not taken to ensure she had taken necessary medication.
  • Christopher Brennan, 15, was a voluntary patient at Bethlem Royal Hospital adolescent unit. On 21 September 2016 an inquest found his death was also contributed to by neglect. The inquest also found cumulative and continuing failures in risk assessment. Coroner Selena Lynch wrote a Prevention of Future Deaths report in December 2016.