13 May 2021

Before HM Senior Coroner for East London, Nadia Persaud
Barking and Dagenham Town Hall
4-12 May 2021

Neil Challinor-Mooney, 51, died on 18 November 2018 after he was found unconscious in his room at Goodmayes mental health hospital in Ilford two days prior. An inquest yesterday (12 May 2021) concluded that Neil’s death was by suicide, caused by gross failures in the mental health care provided to him by the North East London NHS Foundation Trust (NELFT), amounting to neglect.

Neil had been detained under the Mental Health Act 1983 since 1 November 2018, following a significant deterioration in his mental health.

Born in Wales, Neil lived in Romford in supported accommodation. He was a vulnerable adult who had been under the care of NELFT’s community mental health team for many years. Everybody who knew Neil knew of his big heart, his kindness and selflessness. Neil’s family were everything to him; he loved spending time with his nieces and nephews. Being the eldest of six children, Neil always looked out for his five siblings.

In the months leading up to Neil’s death, the inquest heard that there were frequent, poorly planned and communicated changes to Neil’s care co-ordination in the community – accepted by NELFT as being “vital” to Neil’s care.

After Neil’s long-term care co-ordinator left the Trust in April 2018, Neil had a further three different care co-ordinators between then and October 2018. There were no formal handovers between any of Neil’s incoming or outgoing care co-ordinators. Neither Neil, his support worker at his residential placement, nor his family – who had been closely involved in his care for a number of years – were informed of any these changes.

At the inquest, NELFT accepted that this failure to communicate with Neil would have caused him significant distress. It also led to inadequate supervision of his mental health medication in the community (which Neil had asked to be changed from depot injection to oral medication), contributing to his subsequent mental health deterioration and the need for Neil to be admitted to hospital.

In October 2018, a month before his death, Neil was admitted to King George’s Hospital for treatment for diabetes. He was discharged back to his supported accommodation without anyone being informed, and experienced a significant deterioration in his mental health.

This eventually culminated in his treating psychiatrist in the community recommending his urgent admission to a psychiatric inpatient unit. Despite this, Neil was not in fact admitted for a further two days, despite the efforts of his family and support worker, and the fact that Neil had agreed to an informal admission.

After finally being admitted under section to Turner Ward at Goodmayes Hospital under the Mental Health Act, the court heard evidence of numerous issues with Neil’s care including:

  • Poor recording of Neil’s physical health issues – with records describing Neil as having “no issues” despite three falls on the ward requiring his attendance at A&E;
  • Neil was allocated a ‘named nurse’ on admission who went on leave the same day, and did not return until after Neil’s death;
  • A lack of any involvement of Neil’s family or care co-ordinator, despite his distress at being on the ward;
  • Clinical entries in Neil’s records that were significant to a proper assessment of his risk sometimes being completed by staff many days after the interaction with Neil;
  • Clinical entries in Neil’s records that were incorrect, resulting in incorrect information being used to inform his care and treatment;
  • The lack of a structured approach to assessing and documenting Neil’s risks and associated management plans by community and ward-based staff, in accordance with NELFT’s policies.

On 13 November 2018, Neil disclosed to ward staff that he was hearing voices telling him to kill himself, and he disclosed details of how he would make a ligature to do so. Neil repeated this to staff  the following day. Despite these clear indications of his escalating risk of suicide, the items he planned to use were not removed from him after these crucial disclosures. His level of observations – designed to prevent him from harming himself in a period of crisis – were not sufficiently increased.

Despite the fact that the items had apparently been removed from him when he was first admitted to Turner Ward (despite there being no record of this), they were given back to him. The inquest jury could not conclude when the items were mistakenly given back to him – again, no record was ever made.

On the morning of 16 November 2018, Neil was observed at around 08:00 walking towards his bedroom. Trust policy was that Neil should have been positively supported and engaged with; the observing nurse at the inquest accepted that he did no more than glance in Neil’s direction. Shortly afterwards, ward staff found that Neil had tied a ligature using the items he had planned to. Staff attempted to resuscitate him and called an ambulance. Neil was transferred to Queen’s Hospital intensive care unit in Romford, but he did not regain consciousness and he died on 18 November 2018.

During the inquest, NELFT accepted that the root cause of Neil’s death was failure to appropriately manage his disclosure to staff, on two separate occasions over two days, that he intended to use the items as a ligature. NELFT accepted that ward staff had the means and opportunity to ensure Neil did not have access to these items, or to increase the observations on him to constant (or ‘within eyesight’) observations – either of which would have meant that Neil did not have the means or opportunity to create a fatal ligature on 16 November 2018.

After five days of evidence, the inquest jury concluded that Neil’s death was caused by suicide contributed to by neglect. The jury also found that Neil’s care in the community was not appropriately co-ordinated after April 2018 as a result of high staff turnover and the absence of proper handover notes, as well as the failure to notify Neil himself of changes in his care.

The jury concluded that this inadequate record keeping contributed to a deterioration in Neil’s mental health which led to his admission on 1 November 2018. They also found that systemic failures, including in communication, record keeping and inadequate preventative measures to keep Neil safe after disclosing his suicidal ideation, contributed to his death; and that these failures were so serious as to amount to neglect.

During the inquest, the senior mental health nurse (and Clinical Lead for the ward), who took responsibility for failing to remove the items Neil used as a ligature after 14 November, made an identical entry in Neil’s electronic records as another nurse had made 4 days previously stating Neil was “improving”, despite Neil’s increasing risk to himself. The same nurse amended Neil’s records shortly after his death, and at the time an internal investigation was being complied. The coroner confirmed that she would be writing to the Nursing and Midwifery Council– the regulatory and disciplinary body for nursing in the UK – on the basis of this evidence.

The coroner confirmed that she will be sending a Prevention of Future Deaths Report to NELFT, highlighting her concerns that, despite a number of changes having been made to NELFT’s policies and procedures, she was yet to see evidence of how these changes had been implemented in practice, and audited to ensure they were working.

Marie Mooney, Neil’s sister, said on behalf of the family: “Neil was a family man above all else, and our family is devastated to have lost him in these circumstances.

At the start of 2018, Neil was the happiest he had been in years. After his long term care co-ordinator left in April that year, things started to go drastically wrong in his care. Neil and our family repeatedly raised concerns about the management of his medication and how concerned we were about his presentation, but we feel we weren’t listened to.

When Neil was finally admitted to Turner Ward, we thought he would be safe and that he would receive the care he desperately needed. When Neil died, we knew he had been grossly let down, but we were still shocked at some of the evidence we heard in the inquest.

As a family, we remain deeply concerned that staff on Turner Ward failed to document and hand over crucial information relevant to Neil’s risk to himself, and to communicate and share that information either with each other or with us, Neil’s family – despite the Trust’s clear policy on risk management. The jury’s conclusion of neglect reflects what we have always known.

Our family will continue to fight for policy changes to improve mental healthcare for vulnerable people like Neil. We intend to petition the government on this issue.”

Tara Mulcair of Birnberg Peirce solicitors, who represented the family, said: “My clients are grateful to the Senior Coroner and the jury for their careful consideration of the important issues in this case.

The jury’s damning finding of neglect confirms what Neil’s family and their legal team have always known - Neil was failed by NELFT and his death was preventable. Neil’s inquest has highlighted, once again, the systemic failings in risk management, communication and record keeping in Goodmayes Hospital and NELFT’s community mental health team. The Trust has rightly apologised to the family and accepted the findings of the independent investigation.

Had the ligature items been removed from him on either 13 or 14 November, when he voiced to staff his intention and a clear plan to take his life, Neil would be here today. Ultimately, Neil paid for these failings with his life and my clients will bear the loss of Neil’s life for the rest of theirs.”

Nancy Kelehar, INQUEST caseworker, who supported the family, said: The strong conclusions of the jury emphasise how devastating the consequences of failures in basic care and treatment can be. It is fundamental that staff in mental health settings understand the importance of accurate and timely record-keeping and communication of escalating risks.

Sadly, this is another case in which the family’s concerns were not given due weight when Neil was struggling in the community and Neil himself was not listened to when he was in hospital. All mental health settings must adhere to robust record-keeping and risk management in order to prevent further similar deaths in the future.”


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

The family is represented by INQUEST Lawyers Group members Tara Mulcair and Marte Lund of Birnberg Peirce and Tom Stoate of Doughty Street Chambers. They are supported by INQUEST Caseworker Nancy Kelehar.

Other interested persons represented at the inquest are North and East London NHS Foundation Trust (who manage Goodmayes Hospital and the Community Mental Health Team); Barking, Havering and Redbridge NHS Foundation Trust, Riverside (accommodation provider) and the Care Quality Commission.

Other recent deaths involving patients at Goodmayes Hospital:

  • On 4 March 2021, Graeme Irvine, Acting Senior Coroner for the area of East London issued a Prevention of Future Deaths report to NELFT and others in respect of the death of Steven Stout, 40, who took his own life two weeks after he was discharged from Turner Ward. The coroner raised his concerns that future deaths could occur unless action was taken by NELFT. One of the areas of concern highlighted was the failure of staff on Turner Ward, Goodmayes Hospital to accurately record decision on risk management.