A care home resident died after a “collective failure” to intervene in his worsening mental health, a coroner has found.

Senior east London coroner Graeme Irvine found failures to assess Mark Kinzley's mental health or decision-making capacity, even after he was noted to be self-harming, were “a glaring error”.

Mr Kinzley, 61, died in Whipps Cross Hospital on November 1, two days after being found unresponsive in his room at Cambridge Nursing Home in Cambridge Park, Wanstead.

His cause of death was given as brain damage caused by a lack of oxygen.

Leading up to his death, Mr Kinzley had been observed hitting his head, smearing faeces around his room and obsessively repeating the words, “That’s not right! That’s not right!”

Staff had begun seeking a “deprivation of liberty” order, yet never ordered a mental health assessment.

“My concern is about the collective failure between the organisations,” said Mr Irvine. “It’s about the missed opportunity.”

Mr Kinzley was in care due to a serious neurological disorder, Dandy-Walker Syndrome, which left him double-incontinent and with very limited mobility.

He often had to crawl instead of walking and had started suffering fits and seizures.

He was admitted to the home after a period of “self-neglect” which left him frail and underweight.

He also had a history of anxiety and depression and once spent time in Goodmayes Hospital, the inquest was told.

A police investigation into Mr Kinzley's death found he had been in the home for almost a year and had “never had a visitor or a phone call”. No relatives attended his inquest.

In his final months, staff recorded “erratic and unpredictable” behaviour, including “increased episodes of aggression and agitation”.

The court heard he broke equipment in his room, prompting staff to put crash mats around his furniture for his own safety.

He had “fluctuating levels of capacity” and was not allowed to administer his own medication.

The deterioration sparked a referral to The Evergreen Surgery in Wanstead High Street, but no formal mental health or capacity assessment was done.

Dr Matthew Greenfield testified: “I can’t remember the exact questions I asked him but I didn’t get any hostility or signs of distress or agitation when I spoke to him.

"I've asked myself whether I should have challenged him more on his behaviour and documented those responses. But the reason I didn't do that is because it would have been more of an interrogation, rather than a consultation with a patient."

Mr Irvine found no individual failing by Dr Greenfield.

Mr Kinzley was seen around an hour before he died, crawling across his bedroom floor. When a staff member asked if he wanted help, he told them to “f*** off”.

Mr Irvine considered reaching a conclusion of suicide.

“He was a very isolated man,” he said. “He must have been a very lonely person. He was vulnerable in every sense of the word.”

But, he added: “The canvas is rather blank in terms of his intentions.”

He reached a narrative conclusion, saying he could not find on the available evidence that Mr Kinzley intended to take his own life.

“There was a significant doubt about his capacity,” Mr Irvine told the court.

“I do have a concern, following the evidence that I’ve heard, about the absence of a meaningful mental health assessment for Mr Kinzley in the weeks leading up to his death.

“It seems to me that there was a collective failure between those state organisations responsible.”

He said he would write a “prevention of future deaths” (PFD) report to the nursing home, the GP surgery and Redbridge Council, which was responsible for Mr Kinzley’s placement in the home.

While he could not find that a mental health intervention would have saved Mr Kinzley’s life, he said, “In another case, it potentially could have a more profound effect.”

Cambridge Nursing Home (CNH) said its systems ensured "input is always sought from medical professionals when required".

"Those systems were followed in Mr Kinzley's case and the London Borough of Redbridge Safeguarding Team has already concluded that CNH could not have done anything further," it said. 

"Our thoughts are with Mr Kinzley's family."

The Evergreen Surgery said it would work with partners to support the prevention of future deaths. 

Redbridge Council was approached for comment. 

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