Soviya Rajaratnam, 19, died after running away from a psychiatric hospital, and her family claims the NHS said it was too expensive to send her to a secure unit
There was a “missed opportunity” to put a 19-year-old struggling with her mental health into a secure rehab unit prior to her death, an inquest has found.
Soviya Rajaratnam’s family claims that South London and Maudsley (SLAM) NHS Trust considered it “too expensive” to put her into a secure rehab unit the same year she ran away from her carers and was tragically found dead two days later.
Miss Rajaratnam, from Kingston, died on September 9, 2021, after absconding on escorted leave after she had been sectioned under the Mental Health Act. Dr Sohom Das, an expert forensic psychiatrist, said at the teenager’s inquest that there was a missed opportunity “contributed materially” to her death.
Two days before her death, she had been told that she was going to be moved to a locked rehab unit – a long-term placement where patients can be detained and slowly get better.
At Croydon Coroner’s Court, a jury found that consideration “should” have been given to long-term rehabilitation plans while she was in hospital between May and June earlier that year.
The jury foreperson told the court on Friday (September 18): “Soviya’s death was possibly contributed to by the missed opportunity to admit her for locked rehabilitation in May to June 2021.”
According to her family’s lawyer, Patrick Dunne, social worker Adrianna Lazdins suggested she should go into a locked rehab unit during this period of detention.
Mr Dunne claimed a manager in SLAM’s community care team said in an email: “Regarding the locked rehab, it’s very expensive, and SLAM will not pay for that”. Mr Dunne said this was “rather shocking”.
Summing up the evidence heard at the inquest, Assistant Coroner for London South Sebastian Naughton said that Dr Das told the court: “Frankly, I’m confused why it was said it was too expensive – it’s to be based on clinical representation and whether they need it.”
Miss Rajaratnam returned to hospital in August that year. She was on a “general acute ward” at Bethlem Royal, a psychiatric hospital, at the time of her death.
She had been diagnosed with paranoid schizophrenia, PTSD, emotionally unstable personality disorder, borderline learning disability, and she had a history of substance issues.
The coroner said Miss Rajaratnam was told on September 7, 2021, that the plan was to move her to a locked rehab unit. Dr Das said: “On September 7, news was given to her that changed something in her mind. She thought she was going to come out quite soon, then she was going to be detained in the long term. Instead of thinking she needs to jump through the hoops, she’s thinking ‘I don’t know when I will be discharged’.”
He said that being given the “bad news” meant her “risk profile” was increased. “It was appropriate to have leave with escorts, but it should have changed on the 6th or 7th of September 2021,” he added.
Miss Rajaratnam’s mother and a social worker both raised concerns about how she had reacted to the plan to move her to locked rehab.
The jury found that the clinician responsible for her care at the time “should have had greater appreciation of the increased risk”.
The foreperson said: “The way the plan for locked rehab was communicated to Soviya on September 7 also possibly contributed to her death.”
Mental health nurse Oluyinka Obisesan accompanied Miss Rajaratnam on her escorted leave on September 8, as did Odunola Adewoye, a care support worker. She asked to smoke a cigarette, which she was allowed to do off the hospital grounds.
According to the coroner, Ms Obisesan said that “They were either side of Soviya and as soon as they were outside the gate, Soviya ran away”. Ms Obisesan called the police just before 12pm that day.
Miss Rajaratnam was found dead the following day. Her medical cause of death was heroin and synthetic opioid toxicity.
The jury found the probable cause of her death was drug use on September 9, and was probably contributed to by her mental ill health.
According to the coroner, the friend who found her, who was not named, said: “She had attended heavily intoxicated and was very loud. She had asked for drugs and money, but he didn’t give her any.
“He left her in his flat at 1.30pm before returning at 4pm. He found her unresponsive, he couldn’t find a pulse, he rang 999.”
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