Vijaykumar Gadhavi

On the 11th December 2020 I commenced an investigation into the death of Vijaykumar Girishbhai Gadhavi, age 33. The investigation concluded at the end of the inquest on 16th December 2021 with a narrative conclusion. The narrative conclusion was that: Vijaykumar Gadhavi died as a result of a drug overdose whilst he was an in-patient in hospital. He had a known risk of overdosing on hospital wards and had been placed under enhanced care (one to one supervision). There were numerous breaches of the enhanced care policy during the shift when Vijay was able to take the fatal, excessive amount of medication. The evidence does not reveal precisely how and when Vijay took the drug overdose. There is no evidence that he intended to bring about his death at that time.

Mr Gadhavi suffered from chronic pancreatitis, mild learning disability and possibly a persistent somatoform pain disorder (the latter was under investigation at the time of his death). In July and August 2020, whilst an in-patient at Whipps Cross Hospital and whilst under enhanced (1:1 care), Mr Gadhavi carried out a number of self-harming acts. These included overdoses and an attempt to jump from a hospital bridge. On one occasion in August 2020, the member of staff allocated to provide 1:1 care to him, was found to be sleeping. In September 2020, Mr Gadhavi required admission to Whipps Cross Hospital again. There was no alert on his medical records to alert staff to the need for a risk assessment and risk management plan. Fortuitously, he was recognised by a member of staff who had cared for him previously and enhanced care was put in place. Unfortunately, there were a number of breaches of the enhanced care policy. Mr Gadhavi was able to take a fatal overdose of medication whilst he was in in­ patient on the ward.