Jayden Booroff death: 'Mistakes' over absconding patient's care
Peter Walker/BBCInadequate levels of communication, care and record keeping contributed to the death of a 23-year-old man who absconded from a mental health unit, an inquest jury concluded.
Jayden Booroff fled The Linden Centre, in Chelmsford, on 23 October 2020.
A jury gave a narrative conclusion which followed a two-week inquest at Essex Coroner's Court.
The Essex Partnership University NHS Foundation Trust (EPUT) said it made safety improvements.
Speaking after the inquest, Mr Booroff's mother, Michelle Booroff, said: "Knowing that more could have been done to save my son's life is almost too much to bear, and I will simply never recover from my loss."
Family handoutMr Booroff, from Chelmsford, was described as "talented musically" growing up but developed undiagnosed mental health problems.
He was admitted to The Linden Centre on 19 October 2020 after being sectioned for a second time.
Jurors heard that staff did not update his care plan while in the unit and previous written notes about suicidal thoughts and a risk of absconding were not transferred to the relevant electronic SBAR forms (situation, background, assessment, recommendation).
Family photo
Family photoThe inquest heard that his observations, made while he was receiving anti-psychotic medication, were decreased from four times per hour, to once per hour, without a "detailed plan".
A nurse, who Mr Booroff followed into a reception area before absconding, was not wearing her Pinpoint security alarm which she had left in her car.
He left the unit's Finchingfield Ward at 19:56 BST and his body was found at railway tracks nearly two hours later.
The inquest jury concluded:
- There were a "number of structural vulnerabilities which impacted staff safety and security"
- There were "levels of inconsistency with communication and care" which "had they been addressed earlier would have made a difference"
- The use of the Pinpoint security alarm system was "inadequate"
- The reporting of his absconding risk "was not clear enough and led to a lack of awareness"
- That "mistakes were made" in the updating of documents which "failed to capture important information"
The jury said the response from police was "appropriate".
"I just wish he could be playing his piano and living out his life and his dreams and that got taken away from him, because of these fatal errors," added Ms Booroff.
She backed calls from other campaigners to upgrade a public inquiry, investigating EPUT patient deaths, to a statutory inquiry.
Peter Walker/BBC
EPUT said it invested £40m in improvements and claimed the changes resulted in a 60% reduction in absconding between 2019 and 2021.
It said a security video intercom was fitted after the incident.
"I am sorry for the failings in the care provided to Jayden," said trust chief executive Paul Scott.
"We are committed to continuously improving to provide the best possible care for those who need us most."
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