In June 2015 I commenced an investigation into the death of Khuong Lam. The investigation concluded at the end of the inquest where I sat with a jury on 14th July 2017.The medical cause of death was: 1.a A sudden collapse in a 42 year old man with schizophrenia and recent behavioural abnormality taking Quetiapine, after a prolonged struggle and pressure to the neck. The jury returned a narrative conclusion as follows:

Khuong Lam had had a long history of schizophrenia, having first undergone treatment in January 2004. He had periods of stability but also periods of relapse, and in 2007 he was admitted for 8 weeks as an inpatient at Whitchurch hospital. In June 2015 his condition worsened and he was admitted to the Crisis Assessment Ward at Whitchurch Hospital on 15th June 2015 under Section 2 of the Mental Health Act and then transferred to the Psychiatric Intensive Care Ward (PICU) on 23rd June 2015. The Responsible Clinician (RC) was not informed of the transfer and the Section 17 leave form was not revoked or reviewed on transfer to the PICU by the RC. He was granted Section 17 leave on the 19th June and enjoyed such leave on at least two occasions prior to the 25th June outside the hospital grounds. On 25th June 2015 he was taken on a further period of Section 17 leave and absconded. The hospital were informed by the carer of the absconsion and the police were involved to assist in the search. Khuong Lam was traced to Asda café in Coryton. Police officers attended at the café and allowed him to finish his meal before escorting him out of the café via the fire door. He then absconded from the police officers. A search was undertaken but he was not found. At around 2.30pm Khuong Lam saw a on the path and he began to say threats to him and took off his belt with which he hit . There was a struggle in which Khuong Lam put the belt around neck, and then managed to get it off his own neck and put it around the neck of Khuong Lam, intending by that action to counter an imminent threat of harm to himself. Khuong Lam then died. The pathologist gave as his opinion at Khuong Lam died from a combination of factors, any one of which might have been fatal. He also said that the lack of petechiae showed that the belt had only been around his neck for under 15 seconds and in most people this would have just resulted in a sore throat. The police later arrested but no further action was taken against him. .