The inquest into the death of Kevin Clinton found multiple failings by staff on Coral Ward, Luton operated by the East London NHS Foundation Trust.

Kevin Clinton was 31 years old. He attended the Accident and Emergency Department at Luton and Dunstable University Hospital on 22 January 2022 seeking help for his suicidal ideation. He had presented to the department with a home-made noose. He was assessed by staff and was admitted to Coral Ward, a secure mental health unit as a voluntary patient. On 26 January 2022 he was found dead on Coral Wand, having made a ligature from a bedsheet.

Between 17 – 18 January 2023 an Article 2 inquest was held to investigate Kevin’s death. On 18 January 2023 Dr Séan Cummings, HM Assistant Coroner for Bedfordshire and Luton returned a narrative conclusion. 

He found that there were several failures in Kevin’s care, namely:

  • A failure to adequately communicate between staff.
  • A failure to communicate key decisions.
  • A failure to complete management records.
  • Kevin’s care plan was not completed until after his death.
  • There was a focus on treating Kevin’s alcoholism which may have diverted appropriate attention from his suicidality.

Crucially he found that the leadership and supervision of Coral Ward was inadequate.

The family welcome the failings identified by the Coroner.

Stuart Withers represented Kevin Clinton’s family. He was instructed by Jake Fielding of Southerns Law.