Inquest Touching the Death of Ronald Warren

On 11th and 12th May 2017 an inquest took place in Woking into the death of Ronald Warren. Mr Warren was an 82 year old man who was found in the River Thames on 26th July 2015 after he went missing from St Peter’s Hospital A&E department.

On the date of his death, Mr Warren was suffering from hallucinations and was taken by ambulance to hospital. He had been suffering from hallucinations in the preceding weeks. He was also suffering from a suspected urinary tract infection at the time. Mr Warren was triaged and categorised as non-urgent. He waited for over two hours in an A&E department to be seen by a doctor and went missing before the doctor’s assessment took place.

At the inquest conclusion which took place on 12th June 2017, the Coroner concluded that the cause of Mr Warren’s death was accidental drowning.

The Coroner expressed the view that failings had occurred while Mr Warren was in A&E. He considered there to be a failing in the triage process which took place when Mr Warren first arrived at A&E.  In particular, that the nursing staff did not identify from the clinical records that mental illness should have been investigated. Although this would not have resulted in Mr Warren being seen by a doctor sooner, the nursing staff may have kept a closer eye on Mr Warren. The main focus was on Mr Warren’s suspected urinary tract infection and delirium associated with this, rather than any serious mental illness.

The Coroner stated that the triage system used to identify when patients in A&E departments should be seen by a doctor (the Manchester Triage system) is in need of refinement in order to point staff to mental health concerns. Should this have been the case, the care that Mr Warren would have received would have been ‘subtly different’, the Coroner said.  The Coroner will write to NICE (The National Institute for Health and Care Excellence) with his concerns regarding this.

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