PERFORMANCE: The South London and Maudsley Foundation Trust, which provides mental health services in south London, has been criticised by a jury for its “inadequate” response to a patient who later died in police custody.
A narrative verdict from the jury at Southwark Coroners’ Court found that on the day of his death in 2008 Sean Rigg, 40, “displayed clear relapse indicators [and that the trust’s] response to these indicators was inadeqate”.
It added: “[The trust] had failed to put in place a clear and adequate risk assessment and crisis management plan. SLaM failed to communicate and involve Sean Rigg’s family.
“The clinical team responsible for Sean’s care failed to communicate effectively amongst members of their own team and with the staff [of the hostel where Mr Rigg was staying].”
It added that the “good treatment and care of Sean Rigg provided by staff was compromised by their failure to put in place an adequate crisis plan. They were not as proactive as they could have been in effective communications with the family of the clinical team.”
The lack of communication between the agencies involved, including the police, was also criticised.
SLaM was also found to have “failed to ensure” Mr Rigg took his medication. It was said that a failure to undertake a Mental Health Act assessment 10 days before his death, as his condition was deteriorating, “more than minimally” contributed to his death.
Cause of death was recorded as “cardiac arrest, acute arrhythmia, ischemia and partial positional asphyxia” after he was restrained by police.
The trust issued a formal apology to Mr Rigg’s family.
A statement said: “Mr Rigg was a patient of South London and Maudsley Foundation Trust for many years. He had been treated for recurrent mental health problems and had required hospital admission on many occasions. Prior to his death he was living in a supported hostel for people with mental health problems. The team knew him well and clinical staff were trying to work with him to help him stay well and out of hospital.
“Having reviewed the care and treatment we provided to Mr Rigg it is clear that different clinical decisions should have been taken in the days leading up to his tragic death. In particular, we accept that a Mental Health Act assessment should have been undertaken when it became apparent that Mr Rigg was relapsing.
“All the staff involved in Mr Rigg’s care were deeply saddened by his tragic death. We would like to extend our sincere condolences to his family.”
Coroner’s court verdict