Linden Centre: Alarm 'possibly would' prevent patient's absconding

A 23-year-old man may have been prevented from fleeing a mental health unit if all staff were wearing their security alarms, an inquest heard.

Jayden Booroff was found dead after absconding from the Linden Centre in Chelmsford, Essex, on 23 October 2020.

A coroner heard a nurse tried to "grab" Mr Booroff as he fled, but was not carrying her alarm to alert colleagues.

Doreen Mhone, the matron at the time, said the alarm "possibly would have" prevented the incident.

Ms Mhone, who was overseeing three acute wards and is now a service manager, said staff are told to bring their Pinpoint alarms to each shift.

Mr Booroff, described as a talented musician, was sectioned in October 2020 and taken to the Linden Centre, run by the Essex Partnership University NHS Foundation Trust.

The inquest was told he had a history of undiagnosed mental health issues, and had previously been treated at The Lakes in Colchester.

He went missing at about 19:45 BST and his body was found near Chelmsford railway station about two hours later.

Jurors also heard staff were reminded in 2017 to ensure doors were closed behind them after an inpatient "tailgated" a nurse out of the building.

Area coroner Sonia Hayes asked Ms Mhone why a similar incident happened nine days later.

Ms Mhone admitted staff were likely to have been unaware of the new guidance, but added: "We would look at the incident not as an isolated incident, and try to ascertain where it went wrong, have a discussion with the team basically, on what they've learnt from that incident."

Mr Booroff's keyworker on the ward admitted she went on annual leave on 22 October having not completed his care plan.

She told jurors Mr Booroff did not engage with her, adding: "When I came back to work on the Wednesday [the following week] I had paperwork ready to sit with Jayden because I really believed that after the weekend and a few days of rest he might have been able to engage better with myself.

"I had the kind of view that he was into music and arts, so I really wanted to sit with him and see where he wanted to go following admission."

The court heard the junior nurse had not read all of Mr Booroff's previous care notes, which were more than 70 pages long and included suicidal thoughts, and had not updated his risk assessment.

"You can navigate through the system and look at different case notes and histories, but it is not a simple task of clicking and showing all [the records] rolling one after another," she said.

The two-week inquest at Essex Coroner's Court is due to conclude on Friday.

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