Yong Hong
PFD Report
Historic (No Identified Response)
Ref: 2019-0130
Coroner's Concerns (AI summary)
The observation regime advised by the GP was not implemented, and no interpreter was sought to assist with assessment of his needs. Also, no risk assessment was carried out prior to making the decision to return his call bell.
View full coroner's concerns
(1) His GP made an immediate referral to mental health services and advised constant observations, however.
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
Sent To
- Care Quality Commission
- Croydon County Council
- Thornton Heath Medical Practice
Response Status
Linked responses
0 of 4
56-Day Deadline
29 Apr 2019
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 18th July 2017 an investigation was commenced into the death of Yong Kang Hong age 60. The investigation concluded at the end of the inquest on 10th August 2018. The conclusion of the inquest was the medical cause of death being 1a Hypoxic Brain Injury 1b Cardiac Arrest (resuscitated) 1c Suspension (Clinical) and the Conclusion Suicide (contributed to by neglect)
Circumstances of the Death
An asylum seeker with very little English was transferred from hospital to a care home. Displayed self-harm and suicidal behaviour including attempting to strangle himself with his call bell, this was removed. On 5th July the GP was significantly concerned about his suicidal behaviour to make an immediate referral to mental health services and advised constant observations. He could not communicate with staff and no interpreter was sought. His call bell was returned to him, no risk assessment was conducted and no further Input from the GP was sought. His call bell was returned to him and on the morning of 12th July he used it to hang himself from the curtain rail in his bedroom.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.