A DAGENHAM man with a history of suicide attempts jumped in front of a train just four days after being taken to hospital suffering delusions, an inquest heard last Thursday.
Miguel Rodrigues, 37, of Meadow Road, died on 8 August last year at Dagenham Heathway tube station.
In the wake of his death the health service that was treating him has examined the way it works and has changed its policies.
At the inquest into his death last week expert witnesses told of the lurid and graphic hallucinations he suffered and that because of his mental health issues, he had at one point attacked a stranger he accused of raping his dead mother.
After that incident he called the police himself and was taken to Goodmayes Hospital by officers, where duty doctor Dr Tracy Olu-Awoniyi recommended he receive daily visits from the hospital’s Home Treatment Team (HTT).
However, on further consultation, and without any new information coming to light, it was decided that the Assertive Outreach Team would care for him.
This involved scheduled visits with his care co-ordinator Margaret Kailondo on 4 and 7 August. Mr Rodrigues missed the second meeting.
Senior coroner Nadia Persaud, speaking at Walthamstow Coroners Court, said there were missed opportunities to provide more frequent care visits to Mr Rodrigues between the assault incident and his death.
She added: “A plan decided was changed without any new information being available. A thorough assessment was reached and a reasonable plan for him to be seen by the HTT was made. That plan was not carried out.
“Due to the level of risk at the time and the unpredictability of the mental state, Mr Rodrigues should have been seen more frequently than he was.”
The inquest heard how Mr Rodrigues had a long history of mental illness and drug-taking and frequently failed to take his prescribed medication.
Dr William Travers, a member of Waltham Forest HTT, said that having seen the files on Mr Rodrigues, that he should have been either held in hospital or given twice daily visits from the HTT due to the high risk he could pose to others.
However, in a written report, Ms Kailondo described Mr Rodrigues as ‘happy and chatty’ and as having strong insight into drugs being the main cause of his problems.
Dr Desai-Gupta, part of his Community Recovery Team, added: “At the time when I looked at it there were no symptoms of suicidal thoughts and no risk of him harming others. He was coherent and said the attack was linked to drug use.”
On the date of his death, Mr Rodrigues visited his cousin Ivone Barry at 12.30pm, where he told her about the assault and his fear of the bailiffs coming for him after missing two months of council tax.
Threatening to kill himself, Ms Barry said she tried to calm him down, but he left too soon.
Emergency services were called at around 1.45pm and he was pronounced dead from multiple injuries just after 2.30pm.
Toxicology reports showed no signs of drugs in his system, either prescription or illicit, and Ms Barry said she believed more should have been done for him.
She said: “I am just so sad that he has gone and that no one cared to help him. He was such a big part of my life. He was like a brother and a son. I just wanted him to be alive.”
Dr Travers said that following the death, the North East London NHS Foundation Trust had made changes to how they handle such cases, including the protocol for dealing with differences of opinion and the criteria for assessing risk.