Nick J’Dourou in happier times

AN internal investigation into the death of a man in a secure psychiatric unit has warned of a “series of missed opportunities” in making sure he was kept safe.

Nick J’Dourou, 46, was admitted to Highgate Mental Health Centre as a suicide risk but was not checked on every hour as was required under clear regulations.

At some points he was mistaken to be sleeping during monitoring rounds, including by one nurse who cleaned the room and left fresh bed linen as he lay dead on his bed.

The case comes at the time of an ethical debate about whether digital surveillance technology of inpatient rooms – abandoned following an outcry over privacy – should be reinstated.

Mr J’Dourou’s mother Maria told the New Journal: “We thought he’d be safe there – and we were all so happy when he went in because we thought he’d get through it and come out well.

“This was completely avoidable, that is what is heartbreaking for us. It didn’t have to happen.”

Mr J’Dourou, who grew up around Tufnell Park and went to Acland Burghley secondary school, lived with his wife Nicola in St Albans Villas, Parliament Hill.

Diagnosed with bipolar in his late teens, he was described by his family as a “cheeky” man with an infectious laugh, a diverse taste in music, and a slick dresser with a love of fast cars.

Nicola recalled her first date with Nick and “seeing this massive big smile and thinking, ‘Oh, here we go.’ It was love at first sight.”

She said they had laughed a lot together over the years, until 2020, when he began to go downhill after his anti-psychotic medication stopped working.

A few months before his death, doctors tinkered with his prescriptions – in a process called “titration” – that his family said had a severe impact on his mood and behaviour.

Nicola said: “When he was admitted, I could not stress enough he was suicidal. I wasn’t making it up. He tried so many times at home. But it was almost like what we were saying was irrelevant.”

Mr D’Jourou died from asphyxiation, having torn a strip from his pillow case or bedding, one week after being admitted to the low-security Opal ward.

He had repeatedly asked to be moved to Coral ward, which has a far higher level of security.

The NHS internal investigation said Mr J’Dourou’s “suicidal risk was not fully explored” and his care plan “lacked vital information” about his history was “vague”.

It said that a policy of ensuring patients are breathing during welfare checks had not been followed by staff who “appeared mainly task-focused” and showed “no attempt to go above and beyond”.

But, potentially more seriously, staff had been “dishonest and negligent” when they filled out monitoring forms “retrospectively” with inaccurate information.

It said: “The review also found that staff also did not carry out some of the checks as revealed on the CCTV, despite recording this on the general observations form as done.”

In a witness statement to a coroner’s inquest earlier this year, one ward nurse opened a window to the stress NHS workers are under due to funding cutbacks from central government.

They said: “I was preoccupied with how I was going to manage the ward that day, knowing that there were only two support workers that morning instead of three. The tight schedule weighed heavily on my mind, leading me to rush through whatever I was supposed to do that morning, with the serious consequence I am now faced with.”

In his summing up, St Pancras assistant coroner Richard Brittain said: “Mr J’Dourou should have been observed by ward staff on an hourly basis. This did not happen on several occasions on the morning of his death.”

Mr Brittain, in a Prevention of Future Deaths report sent to the North London NHS Foundation Trust (NLFT), raised what he described as the “complex issue” of the lack of digital monitoring of mental health patients.

“Vision-based patient-monitoring systems” – which use infra-red to monitor breathing, pulse and movement – were trialled on Camden mental health wards in Camden.

But the system was abandoned in 2019 following an outcry from privacy campaigners who argued there were issues of “sexual safety” from patients who had not granted consent.

A divisive debate is ongoing in the NHS about whether digital surveillance should be used on mental health wards, with some trusts using it and others refusing to.

“What’s more important, privacy or safety?” Maria asked.

A North London NHS Foundation Trust spokesperson said: “We were saddened by Mr J’Dourou’s death and reiterate our sincere condolences to his family.

“As a trust, we are consistently open to working with partners across the health and care system to improve how we care for vulnerable people, including learning from any death of someone impacted by mental ill health.”