His sister said at the inquest that she was pleading with the hospital for someone to help her brother just before he tragically died
A North London man was ‘failed’ by two hospitals after he sought help before taking his own life. Christopher Karieren went to two hospitals in North London asking for help with his mental health, but a series of failings, including from the police, meant he did not receive the support he needed.
31-year-old Christopher Karieren from Enfield had kept experiencing suicidal thoughts and deteriorating mental health and approached North Middlesex University Hospital and Barnet Hospital’s A&E for help. An inquest heard that the hospitals had failed Christopher, who was tragically found dead a short time after going to both hospitals.
Christopher died after being hit by a train near a station in North London. A coroner’s inquest into his death found that serious shortcomings in his treatment at the hospitals and the response by the North London NHS Foundation Trust ‘probably made more than a minimal contribution’ to Christopher’s death.
On November 12, 2025, Christopher had attended North Middlesex University Hospital with his sister after he had told staff he had wanted to end his life. He remained at the hospital in the emergency department overnight, and throughout the next day, and after a wait of over 36 hours, was discharged on the morning of November 14 into the care of the community crisis home treatment team.
Later that day, he went to Barnet Hospital emergency department by himself and, after being reviewed by the psychiatric liaison team, agreed to voluntarily be admitted to a mental health ward within the North London NHS Foundation Trust when a bed became available.
But a bed never became available, and, with staffing issues the following day and no one-to-one observation, which Christopher needed, he left the emergency department at 7.20pm. Staff at the hospital did not notice that he had left until two hours later.
The Metropolitan Police were also alerted to Christopher going missing at 9.30pm on November 15, and according to Hudgell’s Solicitors, who represented the family at the inquest, they incorrectly applied the ‘Right Care Right Person’ framework and did not begin a missing person investigation.
The Right Care, Right Person framework assesses if the police are the most appropriate service to respond to a mental health-related incident. The call handler recorded that a missing person report was appropriate and alerted the Local missing persons hub team; however, they did not further escalate to a missing person investigation that night.
He was found by British Transport police at 6.54 am on November 16, after he had been hit by a train that morning.
‘His sister was pleading for him to be helped’
Area Coroner for Haringey, Peter Murphy, recorded that Christopher died as a consequence of suicide. He said the non-availability of a bed at the North London NHS Foundation Trust and the lack of one-to-one observation by staff at Barnet Hospital ‘probably made more than a minimal contribution’ to Christopher’s death.
Christopher’s parents, Sharon and Mike Gunard, say his death must lead to changes in how people suffering with their mental health are treated in hospital settings. “My son was completely failed by two hospitals,” said Sharon.
“Just because somebody isn’t physically injured or bleeding out, it doesn’t mean that they are not in pain or in danger. Christopher could feel he was a risk to himself. His sister was with him at North Middlesex Hospital and was pleading for him to be helped, but they were ignored.
“Because he wasn’t violent or aggressive, they classed him as less vulnerable than others. He was dismissed completely, left feeling that nobody cared for him and that nobody was helping him. He was looking for help. He knew he needed help. We, as a family, knew he needed help, but they didn’t listen. Health professionals need to listen to families.
“I don’t want other young men like Christopher to be let down like this. I’ve lost my son, and Christoper’s young son has lost his dad.
In a tribute read out to the inquest, his parents described Christopher as a ‘beautiful soul’ and a ‘heart of gold’. They said: “He’ll be remembered for his kindness and empathy for people. We miss him, his sister misses her brother dearly, and our hearts are breaking that he is no longer with us.”
They added: “He is and will continue to be missed by so many people; he left his mark on this world, which will remain forever, as he touched the hearts of countless people that he encountered during his short life on this earth.”
Solicitor Caroline Murgatroyd, of Hudgell Solicitors, said the case had highlighted ‘serious shortcomings’ in care.
She said: “This is deeply distressing for Christopher’s family. Christopher had sought help. He knew his mental health had been declining and he reached out to health professionals to provide him with the care, treatment and support he needed to keep him safe.
“He spent more than 28 hours in each of the hospitals and was not admitted to a mental health ward.
“At Barnet, he wasn’t observed one-to-one as he should have been due to insufficient staffing for the number of patients requiring one-to-one care. There is no excuse, as there should have been systems in place to ensure all patients received the treatment and support they needed to keep them safe.
“The Inquest highlighted serious shortcomings in care which ultimately contributed to Christopher leaving as he did.”
‘There are important lessons for all organisations involved’
A spokesperson for Royal Free London, the Trust that represents both North Middlesex University Hospital and Barnet Hospital, told MyLondon: “We would like to share our deepest condolences with Christopher’s family at this incredibly difficult time. We apologise wholeheartedly for failing to take full care of him in our emergency department whilst he was waiting for transfer to the specialist mental health service. There are lessons to be learnt for all of the organisations involved in his care, and we are working with mental health colleagues on a number of measures to prevent something like this happening again.”
A spokesperson from the North London NHS Foundation Trust said: “We extend our deepest condolences to Christopher’s family. We are very sorry that Christopher had to wait for admission. We recognise that delays in accessing mental health inpatient beds are a national challenge, and we know that waiting in these circumstances can be very difficult and distressing for patients and their families.
“There are important lessons for all organisations involved in his care, and we are working closely with our partners to strengthen how we keep people safe while they are waiting for admission to mental health services.”
The Metropolitan Directorate of Professional Services (DPS) later referred the matter to the Independent Office for Police Conduct (IOPC). The IOPC carried out a local investigation and subsequently made a number of recommendations, including training and guidance for officers on how the Right Care, Right Person policy should be applied to missing person cases.
A Met Police spokesperson said: “Our thoughts remain with Christopher’s family and loved ones. Since Christopher’s death, we have provided updated training and guidance to officers on how the Right Care, Right Person guidance should be applied to missing person cases.”
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