'Lack of safeguarding' found after patient died

An NHS trust has been criticised for its “lack of safeguarding” in the case of a man who later died.

Christopher Nmaeka Arima-Egwuatu, 24, who was diagnosed with autism spectrum disorder and paranoid schizophrenia, absconded during an escorted trip to a football match.

Mr Arima-Egwuatu, who was an inpatient at The Discovery House in Lincoln, was found dead on 12 May 2023 at a property in Woad Farm Road in Boston, Lincolnshire.

Area coroner Jayne Wilkes recorded a narrative verdict after a four-day inquest at Myle Cross Centre in Lincoln. Lincolnshire Partnership Foundation Trust (LPFT) said it had reviewed policies and procedures following the death.

A jury heard Mr Arima-Egwuatu first absconded on 27 April last year while out on hospital grounds on unescorted leave.

He returned to the ward that evening after spending about £300 on drugs.

Ms Wilkes said Mr Arima-Egwuatu had been described by clinicians as "profoundly vulnerable" in the community and a "model patient".

On 11 May, Mr Arima-Egwuatu then attended an organised event at Lincoln City's ground on escorted leave.

The court heard he absconded again after sitting out the second half and making his way to an unlocked gate before leaving.

The inquest heard that Richard McGuiness, an occupational therapist accompanying Mr Arima-Egwuatu at the match, was "surprised at how fast Chris moved" and "gave no explanation" as to why he did not shout for him to come back.

'No attempt made'

Ms Wilkes said Mr Arima-Egwuatu got a taxi to a property in Woad Farm Road, Boston, and bought heroin and cocaine, which he shared with others and took himself.

The inquest heard other people in the property had "heard him snoring" in the morning of 12 May but he was then found dead in the evening and emergency services were called.

Paramedics arrived and he was pronounced dead just before midnight.

Mr Arima-Egwuatu had been reported to Lincolnshire Police as a missing person on the afternoon of 11 May by a mental health nurse from LPFT.

The jury concluded that there had been "a lack of safeguarding demonstrated by the occupational therapists" at the Lincoln City ground.

It added that there had been "no attempt made to dissuade Chris from leaving".

Additional findings included information provided to Lincolnshire Police by the hospital after Mr Arima-Egwuatu had absconded as "out of date and inaccurate".

It also concluded that Julia Farmer, Mr Arima-Egwuatu's mum, "was not informed" that he had been granted escorted leave and there had been a failure in the "responsible clinician to review the decision to grant escorted leave".

Coroner Wilkes said consultant psychiatrist Jaswant Singh had said he had "taken into account Chris's regret and assurance that it wouldn't happen again" after he first absconded on 27 April.

Despite this, Coroner Wilkes said Mr Singh had accepted he was "aware of Chris's cravings" and that he "didn't have contact with Julia Farmer who had repeatedly requested to speak to him.

After the inquest, Chris Higgins, the trust's chief transformation officer, said: "We are a learning organisation and when things go wrong, we are determined to learn and take action to improve our standards of care when needed.

"We've improved how we work with carers and families, having employed a dedicated carers' lead into the service, acting as a clear liaison point to ensure families are kept involved and informed about the care of their loved one.

"We have also reviewed our policies and procedures to ensure they are robust, and provided guidance to staff so that everyone is clear on their roles and responsibilities."

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