A coroner has warned that patients at a hospital are at risk due to short-staffing after an activist took their own life after wrongly being allowed to leave.
Billy Guedalla was found dead on October 30, 2021, after taking their own life at their home.
The 46-year-old had been allowed to leave the Gardner Ward at the Homerton Hospital in Hackney the day before.
A friend had phoned the hospital raising concerns about Billy and a decision was made not to allow them to leave the ward unescorted.
However, this decision was not communicated to staff – a coroner ruled that this was in part due to management failing to ensure adequate staffing in the ward.
At around 6pm a healthcare assistant allowed Billy to leave alone to get fresh air. Billy did not return.
Staff leaving their shifts did not raise any concern to night staff and Billy’s absence wasn’t discovered until 8pm.
Billy’s family were not made aware that they was missing until they arrived for a visit at 2pm on October 30.
They then had to make the 999 call that led to the discovery of Billy’s body.
Coroner Edwin Buckett has issued a Prevention of Future Deaths (PFD) report following concerns over short-staffing risks to patient safety.
Billy was described as “intelligent, articulate, perceptive and empathetic” and committed to making a difference in the world.
They had undertaken nursing training, volunteered for the Campaign Against the Arms Trade, served as a legal observer during the 2011 riots and a support volunteer for defendants at court.
The East London NHS Foundation Trust (ELFT) admitted that there were failings in Billy’s care due to the inadequate staffing levels.
After Billy’s inquest concluded on May 19, his mother Vicky Guedalla said: “The inquest is over. Billy is still dead. The condolences of the trust so far are empty words that do nothing to soothe our sore hearts.
“It’ll take deeds not just words to do something about the dangerous understaffing that led to Billy’s death.
“Please, ELFT, be urgently pro-active now for the sake of your overworked staff and to protect your vulnerable patients now and in the future.
“You’ve dragged your feet so far, but you have the chance to take the Coroner’s PFD report as a wakeup call to do battle for adequate resources. Please don’t let us down.”
A trust spokesman said: “We at East London NHS Foundation Trust express our deepest condolences to the family and friends of Billy Guedalla.
“The trust fell short of the standard of care expected and for this we are truly sorry.
“A number of improvements have been made following our own review into the circumstances of Billy’s death.
“The coroner has written to us following the recent hearing. We are carefully reviewing the coroner’s comments and are fully committed to addressing any outstanding issues identified.”
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