A Consultant NHS psychiatrist has been criticised for her part in a “system failure” which ended in the death of a patient.
Dr Lenia Constantine was the care co-ordinator for Leon Laga, 24, who was found dead on the steps of Kidderminster police station after taking an overdose of painkillers on January 15, 2005.
During a six-day inquest, it was heard that Dr Lenia Constantine, who works for for Worcestershire Mental Health Partnership NHS Trust, had failed to comply with the Care Programme Approach (CPA) for Mr Laga’s care. She had also not assigned a key worker to Mr Laga, despite his worsening mental health.
She also admitted that she did not fill out a risk assessment form.
Summing up on Tuesday, coroner Geraint Williams said: “A failure to use the form must mean that there’s a gap at the heart of the patient care.”
It was also heard that despite Mr Laga becoming increasingly, offensive, aggressive and paranoid, a multi-disciplinary meeting was not organised for Mr Laga’s carers.
This was an “opportunity lost” said Mr Williams.
He added that the needs of Mr Laga’s family were “totally ignored” by Dr Constantine, because she had failed to arrange a carer’s assessment.
He said: “I found that she [Dr Constantine] was dealing in isolation and taking little effort to look into the future. There was an appropriate system available with the trust.
““All that had to be done was to follow and comply with the CPA. The CPA wasn’t being followed. This meant there was a system failure.”
Mr Laga, who had a long history of self-harm, had arrived at the police station following an argument with his mother when she told him to leave their home because he had been drinking.
In recording his verdict at Stourbridge Coroner’s Court Mr Williams said that Mr Laga’s taking of the painkillers was impulsive and not because he wanted to take his own life.
Dr Ros Keeton, chief executive of Worcestershire Mental Health Partnership NHS Trust, said: “We offer our most sincere apologies to Leon’s family and friends.
“We hope they can accept our assurance that the trust has made substantial improvements in the years since Leon’s death.”
The trust has received an excellent annual rating from the Healthcare Commission based on patient feedback and staff self-assessment.