Mistakes at lewisham hospital allowed robert thomas, 49, who was sectioned, to hang himself with pyjamas an inquest concluded news shopper brain anoxia

He was convinced police thought he was a paedophile and a child murderer, and clambered out of his bathroom window onto the roof, before climbing across the gardens.

Police sectioned him under the mental health act for his own protection on october 3, 2013, after experiencing further delusions that a mob was coming to kill him.

Finding him ‘dishevelled and partially undressed’, detective sergeant peter campbell, of lewisham CID, said: “his behaviour was extremely neurotic, saying he was being chased.”

He was found hanged in his room by staff the very next day.

Mr thomas, a financial director of a consultancy firm, admitted he had been using crystal meth to ‘heighten his sexual pleasure’ for some time, but hid his intravenous drug use from his long-term civil partner for 20 years, nicholas hobbs.Brain anoxia

They shared a home in wales but mr thomas commuted and stayed in london monday – friday.


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Dr ewa okon-rocha said mr hobb’s was: “under the impression that mr thomas has never experimented with illicit substances and he was really against them, and obviously he was not aware of the other issues.”

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Southwark coroners’ court was told he had been seeing, and using the services, of an escort named tony.

It is thought the pair took drugs together, and mr thomas admitted he used the substance between five and seven times a month.

Despite being in a well-paid job, mr hobbs discovered his former partner had racked up more than £20,000 in debt.

The inquest heard mr thomas was diagnosed as HIV positive in 2006, and was on a course of drugs to combat the effects of the virus.

He was under the care of a psychiatrist since then, but had also been prescribed anti-depressants in the months leading up to his death.

Friend tommy madden told the inquest he had ‘really started to crack up’, adding: “his paranoia was obvious.Brain anoxia he kept on saying I was in on it and stuff like that.”

He had suffered previous episodes, once trying to commit suicide in 1982, and shouting at himself while ‘facially gurning’ in 2011.

The inquest also heard mr thomas lost his own father to suicide when he was just 19.

After being sectioned he stayed in lewisham hospital overnight.

Coroner andrew harris said: “the doctor would be having a conversation with him and at times it was clear he was experiencing things in his brain that weren’t happening outside”

But on the ward the next day he was assessed as being calmer and not harbouring suicidal thoughts, and nurses said he was chatting and joking.

Staff reported he asked for crisps and chocolate as he was going to ‘stuff himself’, and asked for a razor as he was having a shower and wanted to ‘groom himself’.Brain anoxia

He reappeared less than half an hour later, but when staff called him to give him medication at 6pm there was no answer.

Giving evidence, nurse roseline saint-james said she knocked on his door, and after receiving no answer turned the light on.

Still not seeing anyone, she went to open the door but noticed a piece of his green pyjamas protruding through the door tied to an anti-barricade mechanism.

As she and colleagues pushed open the door they felt mr thomas fall to the ground, and realised he had hung himself.

They tried to resuscitate him and performed CPR, before he was transferred to kings college hospital.

His family were informed he was effectively brain dead and they switched off his life support machine six days later, on october 9.Brain anoxia

The inquest found that mr thomas has been assessed at lewisham hospital as low risk of harm, and placed on intermittent – rather than one-to-one – observations which gave him the time to take his own life.

He was not checked on by staff for at least an hour before he was found hanging in his room, despite being sectioned because he was a danger to himself.

A representative of the south london and maudsley trust also admitted that all the anti-barricade mechanisms on the doors were faulty and had been replaced.

A spokesperson for south london and maudsley NHS foundation trust said: “the trust offers its sincere condolences to the family and friends of mr thomas.

“following mr thomas’ death in 2013, a full internal investigation was carried out, including an audit of ligature and observations practice and procedures to ensure they comply with safety standards.”