Source · Prevention of Future Deaths
Hugh Burgess: Prevention of future deaths report
Ref: 2026-0413
Date: 8 Jun 2026
Coroner: Sebastian Naughton
Area: South London
56-day deadline: 3 Jul 2026 (stated in the report)
Responses identified: 0 of 1
0 responses identified · 1 indexed addressee
Response deadline: 3 July 2026 (stated in the report).
Coroner's concerns
Coroner’s Concerns (source excerpt)
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.
View full coroner's concerns
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.
(1) There is no power under the Mental Health Act 1983 (“MHA”) to enable health professionals in hospital emergency departments to ensure that individuals who are considered to be in need of urgent admission remain on site pending a formal assessment to determine whether compulsory detention is necessary and appropriate.
(2) This means that some patients who present significant risks to themselves and / or to others as a result of their mental illness who cannot be persuaded to remain at hospital cannot be prevented from leaving should they decide to do so unless a police officer can first attend to exercise their emergency powers pursuant to Section 136 of the MHA.
(3) In contrast, a patient who has been (voluntarily) admitted for treatment may be detained temporarily pursuant to the “holding powers” of Sections 5(2) or 5(4) of the Mental Health Act 1983 should they have a similar change of heart.
(4) The Court heard evidence that there is no robust alternative legal power to enable health professionals to prevent individuals in this cohort from leaving hospital.
(5) The Court heard evidence that this is a longstanding and frequently occurring problem which represents a gap in safety.
(1) There is no power under the Mental Health Act 1983 (“MHA”) to enable health professionals in hospital emergency departments to ensure that individuals who are considered to be in need of urgent admission remain on site pending a formal assessment to determine whether compulsory detention is necessary and appropriate.
(2) This means that some patients who present significant risks to themselves and / or to others as a result of their mental illness who cannot be persuaded to remain at hospital cannot be prevented from leaving should they decide to do so unless a police officer can first attend to exercise their emergency powers pursuant to Section 136 of the MHA.
(3) In contrast, a patient who has been (voluntarily) admitted for treatment may be detained temporarily pursuant to the “holding powers” of Sections 5(2) or 5(4) of the Mental Health Act 1983 should they have a similar change of heart.
(4) The Court heard evidence that there is no robust alternative legal power to enable health professionals to prevent individuals in this cohort from leaving hospital.
(5) The Court heard evidence that this is a longstanding and frequently occurring problem which represents a gap in safety.
Report sections
Investigation and inquest
On 24 March 2021 an inquest was opened into the death of Hugh Burgess (“Hugh”), who died aged 38 years as following a self-administered overdose of [REDACTED] on 5 October 2020.
Hugh suffered from longstanding and enduring mental illness with psychotic features, having had many admissions for psychiatric treatment before his death. Hugh was in receipt of a package of community care from a specialist team. Hugh’s mental health was significantly exacerbated by intermittent drug and alcohol use. The final hearing of the inquest took place between 1-4 June 2026. The inquest examined (among other things) Hugh’s management by the community and hospital teams in the weeks before Hugh’s death.
Hugh suffered from longstanding and enduring mental illness with psychotic features, having had many admissions for psychiatric treatment before his death. Hugh was in receipt of a package of community care from a specialist team. Hugh’s mental health was significantly exacerbated by intermittent drug and alcohol use. The final hearing of the inquest took place between 1-4 June 2026. The inquest examined (among other things) Hugh’s management by the community and hospital teams in the weeks before Hugh’s death.
Circumstances of the death
Hugh was found deceased at his home [REDACTED] on the evening of 5 October 2020, police officers having forced entry after concerns were raised by Hugh’s father the previous day.
In the two months prior to his death, Hugh had relapsed [REDACTED] use, which resulted in fluctuating but serious deteriorations in his mental health. There were two presentations to the emergency psychiatric teams at hospital following which Hugh self-discharged against medical advice from (i) the emergency department on 8 September 2020, and (ii) from a psychiatric ward on 14 September 2020. On both of these occasions Hugh had presented with psychosis, and had expressed intent to suicide and / or serious self-harm and also harm to others if he were not admitted.
In the two months prior to his death, Hugh had relapsed [REDACTED] use, which resulted in fluctuating but serious deteriorations in his mental health. There were two presentations to the emergency psychiatric teams at hospital following which Hugh self-discharged against medical advice from (i) the emergency department on 8 September 2020, and (ii) from a psychiatric ward on 14 September 2020. On both of these occasions Hugh had presented with psychosis, and had expressed intent to suicide and / or serious self-harm and also harm to others if he were not admitted.
Action should be taken
In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.
Copies sent to
- 2. The Chief Executive of Oxleas NHS Foundation Trust
- 3. The National Medical Director, NHS England [REDACTED]
Similar PFD reports Shared signals
Responses identified
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Jul 2026 (stated in the report).
Sent to
- Secretary of State for Health and Social Care, [REDACTED]
Source links
Data: judiciary.uk.