Inquest finds missed opportunity for rehab before teen's death
A jury found that consideration should have been given to long-term rehabilitation plans for Soviya Rajaratnam.
Incident → evidence → outcomeAn inquest jury has found that there was a missed opportunity to place 19-year-old Soviya Rajaratnam into secure rehabilitation before her death. Miss Rajaratnam died on September 9, 2021, after absconding from escorted leave from a psychiatric hospital. Her family has claimed that the South London and Maudsley (SLAM) NHS Trust considered it too expensive to place her in a secure unit.
Consideration for rehabilitation plans
A jury at Croydon Coroner's Court determined that consideration should have been given to long-term rehabilitation plans for Miss Rajaratnam between May and June 2021, while she was in hospital. The jury foreperson stated that Soviya’s death was possibly contributed to by this missed opportunity. Dr Sohom Das, a forensic psychiatrist, told the inquest that the missed opportunity materially contributed to her death. Assistant Coroner for London South Sebastian Naughton expressed confusion over the cost argument, stating that decisions should be based on clinical need.
Miss Rajaratnam, who had been sectioned under the Mental Health Act, was told two days before her death that she was to be moved to a locked rehabilitation unit. This news, according to Dr Das, changed her perception of her discharge timeline, potentially increasing her risk profile. The jury also found that the communication of the locked rehab plan to Miss Rajaratnam on September 7, 2021, also possibly contributed to her death. The clinician responsible for her care at the time should have had a greater appreciation of the increased risk, the jury found.
Circumstances of death
Miss Rajaratnam absconded on September 8, 2021, while on escorted leave from Bethlem Royal psychiatric hospital, where she was on a general acute ward. Her medical cause of death was identified as heroin and synthetic opioid toxicity. The jury concluded that the probable cause of her death was drug use, contributed to by her mental ill health. A friend found her unresponsive in his flat the following day.
According to her family’s lawyer, Patrick Dunne, an email from a manager in SLAM’s community care team stated: “Regarding the locked rehab, it’s very expensive, and SLAM will not pay for that.” Mr Dunne described this statement as “rather shocking”.
Questions this report answers
01What did the inquest find about Soviya Rajaratnam's death?
An inquest jury found there was a missed opportunity to place 19-year-old Soviya Rajaratnam into secure rehabilitation before her death. The jury also found that consideration should have been given to long-term rehabilitation plans between May and June 2021.
02What was the cause of Soviya Rajaratnam's death?
The jury found the probable cause of Soviya Rajaratnam's death was drug use on September 9, 2021. This was contributed to by her mental ill health. Her medical cause of death was heroin and synthetic opioid toxicity.
03Why was Soviya Rajaratnam not placed in secure rehabilitation?
Her family claims the South London and Maudsley (SLAM) NHS Trust considered it too expensive to place her in a secure rehabilitation unit. An email from a manager reportedly stated that SLAM would not pay for it due to the cost.
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