Having examined the evidence and reviewed witness statements at Barnet Coroner’s Court, regarding the death of 65-year-old Raymond Bebb, HM Coroner Andrew Walker recorded a conclusion which found systemic failings at Barnet Hospital.

The Inquest was told that on 28 December 2017, Mr Bebb, who lived in Barnet, absconded from Barnet Hospital and was found around 16 hours later, having been out of hospital all night. He was due to be under 1:1 supervision and had attempted to abscond almost daily. Once found, he was taken to Northwick Park Hospital, where he developed a chest infection, which ultimately caused his death (on 11 January 2018).

The fact that Mr Bebb managed to abscond confirmed that the 1:1 supervision at the hospital was not sufficient, and this represented a serious failing in care. He had a history of absconding and needed to be detained in hospital in a safe environment.

Barnet Hospital had a staff shortage of one nurse on the specialist ward when Mr Bebb absconded and the nurse looking after him had been allocated an additional six patients. However, the system for providing 1:1 support also required review given that Mr Bebb had previously absconded when there were no staffing issues.

Given his history and situation, Mr Bebb was in a precarious position and it is likely that the time he spent out of hospital was detrimental to his health. However, it could not be ascertained if that period out of hospital played a more than minimal part in causing his death.

To ensure the prevention of future deaths is considered, the Coroner has requested that Barnet Hospital review its 1:1 policy, and report back to him regarding their findings. In addition, he said that the hospital should allow nurses to raise concerns at daily meetings regarding those patients requiring 1:1 care so that appropriate measures can be addressed. The Coroner will review whether a formal prevention of future deaths report is required following consideration of the further evidence from the hospital.

Speaking on behalf of the family after the Inquest, Tim Deeming of Tees Law said:
“The day was understandably difficult for Mr Bebb’s family. However, we are all grateful to the Coroner for conducting a detailed investigation. We hope that other hospitals, not just Barnet, review not only their 1:1 policies, but also the care and support they provide to vulnerable patients. This is an opportunity to ensure that such incidents don’t happen again, and we hope that sufficient resources are put in place to ensure that nurses are not overwhelmed and placed in inappropriate situations in which they cannot provide the care which they want to, to such vulnerable patients.”