Christopher McDonald, diagnosed with schizoaffective disorder, died after going AWOL from the National Psychosis Unit at Bethlem Royal Hospital. Following an inquest, the coroner raised serious concerns regarding the South London and Maudsley NHS Foundation Trust's protocols, highlighting failures in conducting individualized assessments and lacking action plans for patients who abscond. Despite guidelines that prescribed assessment before suspending leave, no such evaluation was performed for McDonald, nor did staff accompany police during his return, which the coroner believed could have mitigated distress and potentially altered the outcome.
The inquest ruled that there was no individualized assessment conducted when Mr. McDonald went AWOL, which is against the trustâs own protocols.
Coroner Sian Reeves expressed concern that proper procedures were not followed by SLAM staff, emphasizing the absence of a solid action plan or accompanying staff.
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