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Care errors at mental health unit led to young man's death, inquest rules


Inadequate communication, care and record keeping contributed to the death of a young man who absconded from a mental health unit, an inquest jury at Essex Coroner's Court concluded.

Jayden Booroff, 23, fled Finchingfield Ward at The Linden Centre, Chelmsford, shortly before 8pm on 23 October 2020. His body was found on railway lines two hours later.

Mr Booroff, from Chelmsford, was described as "talented musically" as he grew 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 how Mr Booroff, who used cannabis, dropped out of Mountview College, a south London drama school, in about 2017 and "stopped taking care of himself.”

The inquest heard evidence that 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 situation, background, assessment, recommendation (SBAR) forms.

The inquest was also told 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.

The inquest jury concluded that there were a "number of structural vulnerabilities which affected staff safety and security" and "levels of inconsistency with communication and care" which "had they been addressed earlier would have made a difference."

The jury also said that the use of the Pinpoint security alarm system was "inadequate"; the reporting of Jayden Booroff’s absconding risk "was not clear enough and led to a lack of awareness" and that "mistakes were made" in the updating of documents which "failed to capture important information."

The jury also said the response from police was "appropriate" and returned a narrative verdict following a two-week inquest.

The inquest was told that there had been nine previous incidents of absconding from the Linden Centre between 2017 – 2020, with one incident involving the doors to the Finchingfield Ward, where Jayden Booroff had been detained.

The Essex Partnership University NHS Foundation Trust (EPUT) said it made safety enhancements including investing £40m in improvements and claimed the changes resulted in a 60% reduction in absconding between 2019 and 2021. A security video intercom was fitted after the incident.

Trust chief executive, Paul Scott, said: "I am sorry for the failings in the care provided to Jayden. We are committed to continuously improving to provide the best possible care for those who need us most."

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.

“I just wish he could be playing his piano and living out his life and his dreams but that got taken away from him, because of these fatal errors."

She backed calls from other campaigners to upgrade a public inquiry, investigating EPUT patient deaths, to a statutory inquiry.