Serious failings at a west London mental health hospital contributed to the death of a man who was killed by a fellow inpatient, an inquest has found.
David Siirak, 27, was attacked by Ronnell Dennis while both were inpatients at the NHS Riverside Clinic in Hillingdon on March 1, 2020. He died of his “unsurvivable” injuries three days later.
Dennis, who then absconded from the ward, was caught by police a day later and was sentenced to a hospital order for manslaughter.
On Friday, West London assistant coroner Richard Furniss raised alarm around how the hospital handled the situation, saying it was clear that some staff members had still not received emergency training four years on.
In a narrative verdict seen by the Standard, the jury inquest found that “inadequate” steps were taken by staff after an earlier altercation between Mr Siirak and Dennis just a day before the killing over the use of a private bathroom.
Jurors found the failure to take decisive action “more than minimally” contributed to Mr Siirak’s death.
The jury also found that the ratio of staff to patients on the ward, which cares for those suffering acute mental health problems, was “wholly inadequate” and criticised the “total failings” which allowed Dennis to abscond.
The inquest, held at West London Coroner’s Court, heard that there was a “clear failure” to provide simulation training for similar scenarios, leading to an initial response described by witnesses as “chaos” and “panic”.
Issuing a rare prevention of future deaths warning, Mr Furniss warned hospital bosses of the risk of repeated failings, saying: “The evidence was that various members of your staff had never previously been involved in a real or simulated emergency.
“By ‘simulated emergency’, I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day.
“One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since.”
A spokesperson for Central and North West NHS Trust, which runs the centre, said it sent its “deepest condolences” to Mr Siirak’s family, and was “sorry” for what had happened.
“The incident that led to David’s death was shocking and left many of our staff traumatised,” said the spokesperson.
“We have made significant changes to the way we do things in our hospital units, like the one where this incident took place, and routinely train all staff in resuscitation in order to help avoid something similar ever happening again.
“We hope David’s family and loved ones can take some small comfort from knowing that”.
In a statement released after Mr Siirak’s death, his family said they had suffered a “great and terrible loss”.
"This has been a life-changing experience. Life will never ever be the same for us without David,” they said.
“David was a strong and much-loved young man, and he will eternally be missed by us all.”
