Inquest concludes that leadership and supervision in the hospital ward were inadequate

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 at the time of his death. He attended the Accident and Emergency Department at Luton and Dunstable University Hospital on 22 January 2022 seeking help for his suicidal ideation and presented to the A&E department with a homemade noose.

He was later 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 bed sheet.

Southerns Solicitors were instructed by the family of Kevin after concerns were raised regarding his care and treatment. Kevin had suicidal ideation, a history of poor mental health and was in a vulnerable position.


Following a 2-day inquest in January 2023, His Majesty’s Assistant Coroner, Dr Sean Cummings 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 were inadequate.


The family welcomed the failings identified by the Coroner and found some comfort by the fact it had been recognised that Kevin did not receive the help he needed and deserved.

The family were extremely grateful for the support they received from Southerns solicitors who worked on behalf of the family in conjunction with Stuart Withers of Number 5 Chambers.

The family said that by using Southerns, they were able to understand the process better and felt that they were given a voice to ask questions relating to the concerns they had with Kevin’s care.

If you require a solicitor for an inquest, our team at Southerns will be happy to assist.

Please contact our team on 01282 422711.

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