Mohammed Choudhury
PFD Report
All Responded
Ref: 2026-0005
All 1 response received
· Deadline: 3 Mar 2026
Coroner's Concerns (AI summary)
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known risks.
View full coroner's concerns
(i) The risks identified in respect of on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider. This was of particular concern when he became non-concordant with his anti-psychotic depot medication from mid-September 2022. (ii) There was no MDT plan to address the significant development of non-concordance with his anti-psychotic depot medication from mid-September 2022. (iii) Despite knowng that lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any checks made with his GP as to whether he was remaining complaint with this medication (which he was not).
Responses
Action Taken
The Trust has reviewed and reinforced its policy on medication non-concordance, embedded an audit cycle to ensure compliance, and trained staff to access and use the NHS Summary Care Record to verify prescription issues. (AI summary)
The Trust has reviewed and reinforced its policy on medication non-concordance, embedded an audit cycle to ensure compliance, and trained staff to access and use the NHS Summary Care Record to verify prescription issues. (AI summary)
View full response
Dear Madam
RE: REGULATION 28 REPORT – Inquest touching the death of Mr Mohammed Choudhury.
I am writing to provide a formal response to the concerns set out in the Regulation 28 report that you issued on 8 January 2026 following the inquest touching the death of Mr. Mohammad Choudhury. I have set each of the individual concerns and the Trust’s response out below.
Regulation 28 Concerns:
i. The risks identified in respect of Mr [redacted] on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider. This was of particular concern when he became non-concordant with his anti-psychotic depot medication from mid-September 2022.
Response: The Trust has reviewed and reinforced its operational policy and standard operating procedures regarding medication non-concordance. These now require that missed depot injections or concerns about adherence be formally discussed in the weekly multidisciplinary team (MDT) meeting and documented comprehensively in the electronic patient record.
An audit cycle has been embedded into routine practice to ensure compliance with these standards. A retrospective review conducted during 2024–2025 examined 275 service users on depot within Luton
CMHT, identifying nine individuals where non-compliance had been recorded. In each case, MDT discussion and documented action plans were evident, including increased monitoring, medication review, proactive liaison with families and liaison with relevant agencies involved in the patient’s care. Weekly compliance monitoring is now embedded as business as usual, overseen by Team Managers, with findings reported to the local Health & Social Care Governance Group and escalated through Directorate governance structures where required.
In parallel, risk assessment and safety planning training are being delivered across Community Mental Health Teams. This training strengthens staff skills in formulation-based risk assessment, relapse prevention, recognition of disengagement, and appropriate use of escalation processes, including legal frameworks and multi-agency working. Attendance is mandatory for all CMHT clinical staff.
As the Trust has already taken the steps set out above, I am satisfied that no further action is required.
ii. There was no MDT plan to address the significant development of Mr. [redacted]'s non- concordance with his anti-psychotic depot medication from mid-September 2022.
Response: The MDT has reflected on this learning and strengthened processes accordingly. Where a service user misses a depot injection or demonstrates medication non-adherence, the matter is now formally raised within the weekly MDT and added to the MDT risk register where appropriate. All MDT meetings are attended by the team Consultant, Operational Lead, Depot Clinic Lead, Care Coordinator, Psychologist, Occupational Therapist and wider MDT members. Risk is reviewed, RAG rated, and monitored weekly until resolved or stabilised. Managers and senior clinicians have reiterated the requirement that all discussions, decisions and responsibilities are clearly recorded in the electronic clinical system, including the named clinician responsible for agreed actions.
Where risk escalates or engagement deteriorates and an urgent response is required, cases are reviewed by senior clinicians in real time, and a clear management plan is formulated. This may include increased frequency of contact, liaison with primary care, involvement of family members where appropriate, and consideration of statutory powers if indicated. The emphasis is on timely escalation and documented oversight to ensure risks are neither isolated nor unmanaged.
As the Trust has already taken the steps set out above, I am satisfied that no further action is required.
iii. Despite knowing that Mr. [redacted] lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any
checks made with his GP as to whether he was remaining complaint with this medication (which he was not).
Response: To address this gap, all relevant clinical staff have now been trained to access and use the NHS Summary Care Record (SCR). This enables clinicians to verify prescription issues and collection, thereby reducing reliance solely on self-report. The SCR is now routinely checked, where medication adherence forms a significant component of risk management.
Where a service user with capacity declines medication, enhanced monitoring and documented risk management plans are implemented. If non-compliance persists and risk increases, the case is reviewed to consider the need for a formal Mental Capacity Assessment, involvement of crisis services, or application of Mental Health Act powers where clinically appropriate. Clinicians are also required to have documented discussions regarding family involvement, recognising the important role carers may play in identifying early signs of relapse.
As the Trust has already taken the steps set out above, I am satisfied that no further action is required.
Conclusion
The Trust deeply regrets the circumstances surrounding Mr Choudhury’s death and the distress this has caused to his family. We are committed to learning from this case and have implemented strengthened governance, clearer MDT accountability, enhanced documentation standards, and objective verification processes for medication adherence.
We hope this response provides reassurance that the concerns raised have been carefully considered and that meaningful improvements have been embedded to support patient safety.
I would like to offer my sincere and heart-felt condolences to his family at this difficult time.
RE: REGULATION 28 REPORT – Inquest touching the death of Mr Mohammed Choudhury.
I am writing to provide a formal response to the concerns set out in the Regulation 28 report that you issued on 8 January 2026 following the inquest touching the death of Mr. Mohammad Choudhury. I have set each of the individual concerns and the Trust’s response out below.
Regulation 28 Concerns:
i. The risks identified in respect of Mr [redacted] on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider. This was of particular concern when he became non-concordant with his anti-psychotic depot medication from mid-September 2022.
Response: The Trust has reviewed and reinforced its operational policy and standard operating procedures regarding medication non-concordance. These now require that missed depot injections or concerns about adherence be formally discussed in the weekly multidisciplinary team (MDT) meeting and documented comprehensively in the electronic patient record.
An audit cycle has been embedded into routine practice to ensure compliance with these standards. A retrospective review conducted during 2024–2025 examined 275 service users on depot within Luton
CMHT, identifying nine individuals where non-compliance had been recorded. In each case, MDT discussion and documented action plans were evident, including increased monitoring, medication review, proactive liaison with families and liaison with relevant agencies involved in the patient’s care. Weekly compliance monitoring is now embedded as business as usual, overseen by Team Managers, with findings reported to the local Health & Social Care Governance Group and escalated through Directorate governance structures where required.
In parallel, risk assessment and safety planning training are being delivered across Community Mental Health Teams. This training strengthens staff skills in formulation-based risk assessment, relapse prevention, recognition of disengagement, and appropriate use of escalation processes, including legal frameworks and multi-agency working. Attendance is mandatory for all CMHT clinical staff.
As the Trust has already taken the steps set out above, I am satisfied that no further action is required.
ii. There was no MDT plan to address the significant development of Mr. [redacted]'s non- concordance with his anti-psychotic depot medication from mid-September 2022.
Response: The MDT has reflected on this learning and strengthened processes accordingly. Where a service user misses a depot injection or demonstrates medication non-adherence, the matter is now formally raised within the weekly MDT and added to the MDT risk register where appropriate. All MDT meetings are attended by the team Consultant, Operational Lead, Depot Clinic Lead, Care Coordinator, Psychologist, Occupational Therapist and wider MDT members. Risk is reviewed, RAG rated, and monitored weekly until resolved or stabilised. Managers and senior clinicians have reiterated the requirement that all discussions, decisions and responsibilities are clearly recorded in the electronic clinical system, including the named clinician responsible for agreed actions.
Where risk escalates or engagement deteriorates and an urgent response is required, cases are reviewed by senior clinicians in real time, and a clear management plan is formulated. This may include increased frequency of contact, liaison with primary care, involvement of family members where appropriate, and consideration of statutory powers if indicated. The emphasis is on timely escalation and documented oversight to ensure risks are neither isolated nor unmanaged.
As the Trust has already taken the steps set out above, I am satisfied that no further action is required.
iii. Despite knowing that Mr. [redacted] lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any
checks made with his GP as to whether he was remaining complaint with this medication (which he was not).
Response: To address this gap, all relevant clinical staff have now been trained to access and use the NHS Summary Care Record (SCR). This enables clinicians to verify prescription issues and collection, thereby reducing reliance solely on self-report. The SCR is now routinely checked, where medication adherence forms a significant component of risk management.
Where a service user with capacity declines medication, enhanced monitoring and documented risk management plans are implemented. If non-compliance persists and risk increases, the case is reviewed to consider the need for a formal Mental Capacity Assessment, involvement of crisis services, or application of Mental Health Act powers where clinically appropriate. Clinicians are also required to have documented discussions regarding family involvement, recognising the important role carers may play in identifying early signs of relapse.
As the Trust has already taken the steps set out above, I am satisfied that no further action is required.
Conclusion
The Trust deeply regrets the circumstances surrounding Mr Choudhury’s death and the distress this has caused to his family. We are committed to learning from this case and have implemented strengthened governance, clearer MDT accountability, enhanced documentation standards, and objective verification processes for medication adherence.
We hope this response provides reassurance that the concerns raised have been carefully considered and that meaningful improvements have been embedded to support patient safety.
I would like to offer my sincere and heart-felt condolences to his family at this difficult time.
Sent To
- East London NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
3 Mar 2026
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 23 January 2023 I commenced an investigation into the death of Mohammed Ashraful Islam CHOUDHURY aged 26. The investigation concluded today, 6 January 2026, after a four day inquest hearing, with the following Narrative Conclusion: The Deceased was unlawfully killed on 11 January 2023 by another resident in his supported accommodation, who suffered with paranoid schizophrenia, unusually, associated with violent behaviour; this other resident had stopped being concordant with medication from mid-September 2022 and, it was possible, that the Deceased’s death was caused, in part, because the risks of this had not been appropriately addressed by mental health services.
Circumstances of the Death
The Deceased, under the care and treatment of his community mental health team had been residing at Biscot House since April 2022. Prior to his arrival there, on 5 February 2019, another male, also under the care and treatment of the same community mental health team, had been placed there. During his stay, this other resident had relapsed on 2 occasions in 2019 and 2020 requiring detention under the Mental Health Act, during which time, he had been diagnosed with paranoid schizophrenia, the treatment for which was medication and psychological therapy. Whilst there were periods when his psychosis was manageable, there were also times when it escalated and, unusually, was associated with violent behaviour. By the time of this resident’s hospital discharge in August 2020, Biscot House had concluded that his needs had escalated since his original assessment and that he could no longer be regarded as having ‘low level’ support needs; although, they had been persuaded to take him back, this had been on a temporary basis only whilst a 24/7 hour supported placement was sought, along with an enhanced care package to support his concordance with medication in the meantime. However, no alternative placement for this resident was ever found and, when the Deceased moved into Biscot House, he was given the room next door to him. In May and June 2022, this resident complained to the Deputy Manager of Biscot House about the Deceased playing his music and not flushing the toilet properly. Despite being aware that this resident lacked insight into his illness and, as such was at risk of becoming non-concordant with his medication, in July 2022, the mental health team chose to cancel the care services who had been supporting him with his prescribed oral medication, without any prior checking with his GP surgery that he was still ordering and receiving his prescriptions (which he was not). On 18 September 2022, after this resident’s GP practice had mistakenly informed him that he had been discharged from mental health services on 9 September 2022, he subsequently refused to take his depot and continued to refuse to do so thereafter. Even though it was known that his mental health would deteriorate after that point, and that such deterioration could include violent and aggressive behaviour, the measures taken by mental health services to address his non-concordance with medication were insufficient to avoid the ‘real and immediate risk’ that he then posed to the Deceased; appropriate safety netting measures in the form of a clear MDT plan (to include an alternative medication regime, mental health act assessment, and/or effective increased surveillance) could and should have reasonably been taken at that time. On 9 and 10 January 2023, this resident again complained about the Deceased playing music and being loud and, at 09.47 hours on 11 January 2023, he sent a text to the Deputy Manager stating: “Both flushing meconism’s on the upstairs toilets are malfunctioning”. Around 40 minutes afterwards, at 10.25 hours, this resident attacked and stabbed the Deceased , inflicting a single stab wound to the front left of his chest causing him an injury to his heart that was not survivable; the Deceased’s death was confirmed at Luton & Dunstable Hospital at 14.10 hours that same day.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.