Inquest concludes ‘neglect’ by East London NHS Foundation Trust contributed to death of “gentle giant” Desmond Maddix after he was fatally injected with heroin at a mental health unit in Luton

Inquest concludes ‘neglect’ by East London NHS Foundation Trust contributed to death of “gentle giant” Desmond Maddix after he was fatally injected with heroin at a mental health unit in Luton

Patient in East London NHS Foundation Trust secure mental health unit smuggled drug paraphernalia into a ward for vulnerable people, including 10 syringes and a fatal dose of heroin.

The incident was highlighted by the coroner as a “failure of the most serious kind”.

The inquest into the death of 36-year-old Desmond Maddix has concluded at Luton and Bedfordshire Coroner’s Court. Mr Maddix was a mental health inpatient who died on 1 July 2017 after he was injected with heroin by another patient, ‘Mr Z’, at Ash Ward, Luton, an acute psychiatric unit run by East London NHS Foundation Trust (ELFT).

HM Assistant Coroner Tom Stoate found that Mr Z unlawfully killed Mr Maddix and that his death was contributed to by a combination of failures in care and safeguarding on the part of ELFT, which amounted to neglect.

Mr Z was admitted voluntarily to the ward on 29 June 2017. He had a history of drug use and was known from previous admissions to supply drugs to vulnerable patients.

On 1 July 2017, Mr Z left the ward on a period of unescorted leave. The staff did not search or assess him on his return. Within less than an hour and a half of his return, he had injected Mr Maddix with a fatal dose of heroin. Staff found Mr Maddix unresponsive shortly after, and despite resuscitation attempts, he was pronounced dead later that evening.

Mr Z was found to have smuggled street heroin and various drug paraphernalia onto the ward undetected, which he used to subsequently administer Mr Maddix, who was described as ‘highly vulnerable’ and lacking capacity, with the fatal dose.

Mr Z is currently serving a prison sentence for manslaughter in relation to Mr Maddix’s death. The inquest, which concluded on 6 December 2022, examined the inpatient care of Mr Maddix and his safeguarding from the risks posed by Mr Z.

The Coroner found that Mr Maddix was unlawfully killed by Mr Z, consistent with the outcome of the criminal trial. However, he also identified a host of failings on the part of the Trust, which he found contributed to Desmond’s death. These included an inadequate understanding of the risk posed by Mr Z, ‘inadequate and inconsistent’ risk assessments of Mr Z, inadequate observation levels and the fact that there was no search of Mr Z upon returning from unescorted leave.  The Coroner found that had a combination of these measures been properly performed, they would have prevented Mr Maddix’s death.

The Coroner concluded that these failures together amounted to neglect by ELFT, constituting a gross failure to provide Mr Maddix with basic medical care, including the provision of a safe ward environment that minimized the risk posed to Mr Maddix regarding the supply and use of illicit drugs. The Coroner remarked that a finding of neglect was necessary to mark the incident as a failure “of the most serious kind”.

Mr Maddix was admitted to Ash Ward on 19 June 2017 after becoming severely unwell. He had a history of serious mental illness and was diagnosed with treatment-resistant Paranoid Schizophrenia. Staff who cared for Mr Maddix described him as a ‘gentle giant’ and a ‘quiet and lovely guy’ who was quick to make people laugh.

The inquest heard how ward staff recognised Mr Maddix as someone vulnerable to being led by others into taking illicit drugs; this was a ‘constant background risk’ for Mr Maddix, especially when he was unwell. He did not have the capacity to make any decisions about drug use and was dependent on ward staff to protect him from these risks. The toxicology report prepared after his death suggested that Mr Maddix had little or no tolerance for heroin and was not a regular user of the drug.

When Mr Z was admitted to the ward on 29 June 2017 as an informal patient, staff immediately raised concerns about his history of supplying drugs to vulnerable patients.  This included an incident in March 2017, when Mr Z had been discharged from the same ward for reportedly supplying drugs and alcohol to other patients, including to Mr Maddix. The court heard evidence from the Ward Manager that Mr Z’s risk to others should have been assessed as ‘high’ on admission, which should have triggered further safeguards, including more frequent observations.

Despite this, Mr Z’s risk to others was assessed as ‘low’ on admission. On 30 June 2017, the day before Mr Maddix’s death, Mr Z’s observation levels were reduced, without explanation, to the lowest level of hourly checks. In the same period, Mr Maddix had also been reduced to hourly observations without any clinical rationale.

On the morning of 1 July 2017, the court heard how Mr Z was agitated and made repeated requests to leave the ward, purportedly to collect some money.  One member of staff became suspicious that he may be attempting to procure drugs, and another that he wanted to leave the ward to pick them up. The Ward Manager at the time testified that since Mr Z’s risk of using drugs was well known, a robust risk assessment would have been required if he were to leave the ward unescorted. However, the Trust accepted that a risk assessment was not carried out for Mr Z when he left on 1 July 2017, nor when he returned later that day.

CCTV footage and other evidence obtained by the police in their investigation showed that whilst he was on leave, Mr Z purchased ten syringes and other drug paraphernalia from a local pharmacy. He had also withdrawn £200 from his bank account but returned to the ward with only £60; it was considered most likely he had used the missing £140 to purchase a quantity of heroin.

Mr Z was observed returning to the Ward at about 18:00 on 1 July 2017 by a member of staff. She described him as ‘in a heightened state’ and became suspicious that he may be hiding something.  Although it was Trust policy to search patients upon returning from leave, no member of staff searched Mr Z upon his return.

Between 18:15 and 19:30, Mr Z injected Mr Maddix with a fatal dose of heroin. At approximately 19:30, Mr Maddix was observed sitting in the communal lounge with his back against the wall.  At 19:35, the staff realised he was unresponsive and sounded the emergency alarm. However, despite resuscitation attempts and swift attendance by paramedics, Mr Maddix could not be saved. He was pronounced dead in the Luton and Dunstable hospital at 21:15 that evening.

The court heard further evidence about the challenges and conditions at Ash Ward, which caused it to fall below the ELFT expected standards of care. This included the ‘standalone’ nature of the ward, which is not within a hospital or larger clinical context, and the fact that the ward then had 27 beds, which was more than the maximum recommended by the Royal College of Psychiatrists.

There had also been a sequence of serious incidents in the past year that had raised similar concerns, such as inadequate management when searching for informal patients wanting to go on leave which reportedly took its toll on staff morale and resilience.

The Coroner considered that sufficient steps had been taken, now five years on, into learning lessons and making the necessary improvements to the ward environment and did not issue a Prevention of Future Deaths Report.

Alice Hardy and Hayley Chapman of Hodge Jones & Allen acted for Mr Maddix’s family. The family were represented at the inquest by Laura Profumo of Doughty Street Chambers.

Desmond’s family said: “Desmond who was a gentle giant and loved by many, has been and will continue to be greatly missed. While there is no way we can bring Desmond back, we hope the East London NHS Foundation Trust learns from his death and can prevent the future deaths of innocent and vulnerable people. Desmond went to Ash Ward as it was supposed to be the best place for him to recover fully, but unfortunately, it was the reason his life was taken too soon. Let his death be a wakeup call for the East London NHS Foundation Trust and the wider NHS.”

Hayley Chapman, Solicitor at Hodge Jones & Allen, said: “Desmond’s death is a tragedy,  and was entirely preventable. It is deeply concerning that within two days of Mr Z’s admission to a secure NHS ward, he was able to smuggle in class-A drugs and other paraphernalia and use them to take Desmond’s life. There is no doubt that staff in mental health inpatient settings do an extremely difficult job, yet the Coroner’s finding of neglect reflects that the preventative measures required in this case were not advanced: they were part of Desmond’s basic care. We hope that lessons can be learned so that another family does not have to go through what Desmond’s have done.”