A man took his own life after a Kingston hospital staff failed to check on him for more than three hours.

Lajos Mandrik, 37, was meant to be observed by staff four times an hour when he died on the Ellis Ward of Tolworth Hospital, in Surbiton, on September 13, 2023.

Richard Furniss, Assistant Coroner for West London, said Mr Mandrik died during a period of non-observation caused by human error and a faulty allocation system, which has now been improved.

But Mr Furniss said evidence given during Mr Mandrik's inquest raised other concerns.

He said South West London and St George's Mental Health NHS Trust, which runs the hospital, were not carrying out general and intermittent observations on the Ellis Ward in line with policy.

In a new prevention of future deaths report, Mr Furniss said if this was and remained the culture on the Ellis Ward, it could also be the culture on other wards run by the trust.

On the day of his death, Mr Mandrik, who had paranoid schizophrenia, had been allocated four observations an hour at the hospital.

The report said no staff member was allocated to carry out these intermittent observations between 2.45pm and 6.05pm, however, as a result of "human error within an inadequate system".

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The inquest into Mr Mandrik's death, which concluded on April 1, found he died as a result of suicide contributed to by neglect.

The coroner said evidence given by healthcare assistants (HCAs) at the inquest, who are usually responsible for carrying out general and intermittent checks during the day, showed "observations were and are not carried out properly".

The report said the trust's policy was that all observations should include an attempt at engagement with the patient, but written logs suggested this did not happen most of the time – then, in September 2023, and now.

It said this impression appeared to be confirmed by the evidence of HCAs at the inquest.

The report said: "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)."

The coroner warned the trust should take action to prevent future deaths.

The trust must respond with a timetable of action to address the coroner's concerns by June 3, or explain why no action is proposed.

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A trust spokesperson said: "We are deeply sorry for the failings in Lajos's care, and we offer our heartfelt condolences to his family and loved ones.

"We fully acknowledge that the care and treatment we provided to Lajos fell short of the standards he deserved and that we strive to offer.

"A full investigation identified issues with the electronic system used to allocate staff for patient observations.

"We acted immediately to remove this system and replace it with a clear process that identifies the staff member assigned to observe individual patients.

"The coroner also highlighted the need to further improve engagement during observations and how this is recorded. We are taking prompt action to address this, ensuring that our staff are supported to deliver safe, effective and compassionate care."

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