Lajos Mandrik
PFD Report
Response Pending
Ref: 2026-0219
Coroner's Concerns (AI summary)
Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with patients during observations.
View full coroner's concerns
However, The Trust's policy - in common with that of other Trusts - is that all observations should include an attempt, at least, at engagement. The written logs of observations suggest that, most of the time, no attempt is made at engagement during observations, in September 2023 or now. Intermittent observations may be recorded as, for example, 'Corridor - pacing' because the HCA has seen the patient but not attempted to engage with the patient. General observations, once per hour, appear to be no more than a headcount to make sure all patients are present on the ward (then and now). This impression, gleaned from the documentation, appeared to be confirmed by the oral evidence of HCAs at the inquest. It appears that the general and intermittent observations on Ellis Ward are not being carried out in accordance with the Trust's policy. If this was and remains the culture on Ellis Ward, it may also be the culture on other wards operated by the Trust (since some staff work on more than one Trust ward).
Sent To
- South West London and St George’s Mental Health NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
3 Jun 2026
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 11 October 2023 an investigation was commenced into the death of Lajos MANDRIK. The investigation concluded at the end of the inquest on 1 April 2026 . The conclusion of the inquest was Suicide contributed by Neglect and the jury made other findings. The medical cause of death was 1a Suspension 1b 1c II
Circumstances of the Death
On 13 September 2023, the Deceased had been assigned intermittent observations - four per hour - on Ellis Ward in Tolworth Hospital (a secure acute ward in a mental health institution operated by South West London and St George's Mental Health NHS Trust - 'the Trust'). As a result of human error within an inadequate system, no member of staff was allocated to carry out intermittent observations between 1445 and 1805 hours on 13 September 2023, during which time the Deceased hanged himself. Because the member of staff allocated to intermittent observations was also expected to carry out general observations, it follows that there were no observations (save for the four patients on 1:1 observations) during that time. Intermittent and general observations were and are generally carried out during the day by Healthcare Assistants (HCAs). The inquest heard evidence from a number of HCAs during the inquest and it was clear that observations were and are not carried out properly. The Deceased's death occurred during a period of non-observation caused by human error and a faulty system of allocation which has now been changed. That in itself is not the current cause for concern.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.