On the 25th of July 2015 | opened an investigation the death of Benjamin Thomas Brown 35 years old. The inquest concluded on Totchirg t the March 2016. The conclusion of the inquest was Natural Causes, the medical case of death was Ia Sudden Cardiac Death to Cardiac Arrhythmia and under paragraph 1 ~ Schizophrenia, Fatty Liver Disease

Benjamin Thomas Brown was a patient on Avon Ward at the Dennis Scott Unit at Edgware Community Psychiatric Hospital detained under section 2 of the Mental Health Act Mr. Brown had a sixteen-year history of treatment resistant Schizophrenia: Mr: Brown was admitted to Edgware Community Hospital on the 18u 2015_ Mr. Brown was On 15-minute observations the last of which was recorded &.15. A Registered Mental Health Nurse from an agency was not told about the need for 15 minute observations and taken hourly observations was pressured into entries in the Patient Observation Records for times when Mr: Brown was not observed, There were other entries on the Patient Observation Records that having been checked with CCTV evidence confirmed that entries had been made into the Patient Observation Records when no observation had been made_ Day due July having making

Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) An at 8.30 was entered after Mr: Brown was found to be unresponsive at 8.4Sam The time that Mr: Brown suffered a cardiac arrest is to have been between Sam and 8.45am Resuscitation was initially provided with nursing staff and the doctor and then by the London Ambulance Service who arrived at the Dennis Scott Unit at 9.15 am, Mr Brown was recognized as having died at 10.06 It is likely that the identification of the cardiac arrest was identified outside the time window for successful resuscitation_

In my opinion action should be taken to prevent future deaths believe you [ANDIOR your organisation] have the power to take such action.