Source · Prevention of Future Deaths
Lajos Mandrik
Ref: 2026-0219
Date: 4 Jan 2026
Coroner: Richard Furniss
Area: West London
Responses identified: 0 / 1
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Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with patients during observations.
Date
4 Jan 2026
56-day deadline
3 Jun 2026
Responses identified
0 of 1
Coroner's concerns
Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with patients during observations.
View full coroner's concerns
However, The Trust’s policy – in common with that of other Trusts – is that all observations should include an attempt, at least, at engagement. The written logs of observations suggest that, most of the time, no attempt is made at engagement during observations, in September 2023 or now. Intermittent observations may be recorded as, for example, ‘Corridor – pacing’ because the HCA has seen the patient but not attempted to engage with the patient. General observations, once per hour, appear to be no more than a headcount to make sure all patients are present on the ward (then and now). This impression, gleaned from the documentation, appeared to be confirmed by the oral evidence of HCAs at the inquest. It appears that the general and intermittent observations on Ellis Ward are not being carried out in accordance with the Trust’s policy. If this was and remains the culture on Ellis Ward, it may also be the culture on other wards operated by the Trust (since some staff work on more than one Trust ward).
Report sections
Investigation and inquest
On 11 October 2023 an investigation was commenced into the death of Lajos MANDRIK. The investigation concluded at the end of the inquest on 1 April 2026 . The conclusion of the inquest was Suicide contributed by Neglect and the jury made other findings.
The medical cause of death was
1a Suspension 1b 1c
The medical cause of death was
1a Suspension 1b 1c
Circumstances of the death
On 13 September 2023, the Deceased had been assigned intermittent observations – four per hour – on Ellis Ward in Tolworth Hospital (a secure acute ward in a mental health institution operated by South West London and St George’s Mental Health NHS Trust – ‘the Trust’).
As a result of human error within an inadequate system, no member of staff was allocated to carry out intermittent observations between 1445 and 1805 hours on 13 September 2023, during which time the Deceased hanged himself. Because the member of staff allocated to intermittent observations was also expected to carry out general observations, it follows that there were no observations (save for the four patients on 1:1 observations) during that time.
Intermittent and general observations were and are generally carried out during the day by Healthcare Assistants (HCAs). The inquest heard evidence from a number of HCAs during the and it was clear that observations were and are not carried out properly.
The Deceased’s death occurred during a period of non-observation caused by human error and a faulty system of allocation which has now been changed. That in itself is not the current cause for concern.
As a result of human error within an inadequate system, no member of staff was allocated to carry out intermittent observations between 1445 and 1805 hours on 13 September 2023, during which time the Deceased hanged himself. Because the member of staff allocated to intermittent observations was also expected to carry out general observations, it follows that there were no observations (save for the four patients on 1:1 observations) during that time.
Intermittent and general observations were and are generally carried out during the day by Healthcare Assistants (HCAs). The inquest heard evidence from a number of HCAs during the and it was clear that observations were and are not carried out properly.
The Deceased’s death occurred during a period of non-observation caused by human error and a faulty system of allocation which has now been changed. That in itself is not the current cause for concern.
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Report details
- Reference
- 2026-0219
- Date of report
- 4 January 2026
- Coroner
- Richard Furniss
- Coroner area
- West London
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Jun 2026.
Sent to
- South West London and St George’s Mental Health NHS Trust