An activist took their own life after being wrongly allowed to leave a dangerously short-staffed NHS hospital while on suicide watch, an inquest has found.
Billy Guedalla, 46, was admitted to the Gardner ward of Homerton Hospital in east London during a mental health crisis in October 2021, and a clinical decision was taken not to let them leave for their own safety.
However, the decision was not passed on to staff and a healthcare assistant let Billy leave the ward for fresh air, Poplar coroners court heard.
Staff at the hospital failed to tell police about the high risk of suicide, and it was Billy’s family – who had not been alerted to the situation – who made the 999 call that led to the discovery of Billy’s body.
Coroner Edwin Buckett, who presided over the inquest last month, has now issued a report warning of future deaths and calling for urgent action from East London NHS Foundation Trust (ELFT).
Vicky Guedalla, Billy’s mother said on behalf of the family: “The inquest is over. Billy is still dead. The condolences of the Trust so far are empty words that do nothing to soothe our sore hearts.
“It’ll take deeds not just words to do something about the dangerous understaffing that led to Billy’s death.
“Please, ELFT, be urgently pro-active now for the sake of your overworked staff and to protect your vulnerable patients now and in the future.
“You’ve dragged your feet so far, but you have the chance to take the Coroner’s report as a wake-up call to do battle for adequate resources. Please don’t let us down.”
The family paid tribute to Billy as “intelligent, articulate, perceptive and empathetic” who had dedicated their life to helping others.
Billy undertook nursing training, volunteered for the Campaign Against the Arms Trade, was an LGBTQ+ activist, and acted as a legal observer on protests and during the London 2011 riots.
Billy, who had suffered mental health issues since 2013, was admitted to hospital for 11 days at the start of October 2021, and returned to Gardner ward on 26 October during a crisis.
The inquest heard staff did not comply with the patient admission policy, records were not updated, and key risk information in Billy’s case was not shared with staff.
Billy required 1-1 support which could not be delivered due to staff shortages, which also caused the failure to pass on to staff a clinical decision to not allow Billy to leave the ward on October 29.
When Billy went missing, the news was not handed over to the night staff, a call was made to Billy’s mother without leaving a message, and a 2am call to police did not pass on information that the missing person was potentially suicidal.
Hospital staff were told by police to call an ambulance but waited 12 hours to do so, and Billy’s family only discovered they were missing during a visit to the hospital at 2pm on October 30.
The NHS Trust carried out a serious incident investigation after the death, which wrongly concluded the hospital had been adequately staffed.
Jo Eggleton, from Deighton Pierce Glynn solicitors which represented the family, said it was “the tenacity of a bereaved family” which helped to “uncover the truth of the failings that led to their loved one’s death.
“Instead of focusing on identifying what went wrong and learning lessons the Trust and their solicitors have consistently tried to limit public scrutiny of their actions, including repeatedly ignoring Coroner’s directions and telling at least one witness to remove relevant evidence from their statement”, she said.
Selen Cavcav, Senior Caseworker at INQUEST, said: “What happened to Billy should have never happened. Those responsible for running the unit ought to have known that their staffing levels were dangerously low, and their risk assessment systems were completely unreliable to keep vulnerable patients safe. Empty platitudes do not save lives. Now is the time to take urgent action to address the failures so clearly spelled out by the coroner at this inquest.”
The Trust has been given until August 4 to respond to the failings laid out in the Coroner’s report.
In a statement, it said: “We at East London NHS Foundation Trust express our deepest condolences to the family and friends of Billy Guedalla.
“The Trust fell short of the standard of care expected and for this we are truly sorry.
“A number of improvements have been made following our own review into the circumstances of Billy’s death. The coroner has written to us following the recent hearing. We are carefully reviewing the coroner’s comments and are fully committed to addressing any outstanding issues identified.”
