Mansoor Zaman

I am Graeme Irvine, senior coroner, for the coroner area of East London

On 10 th January 2025, this court commenced an investigation into the death of Mansoor Dawud Zaman aged 27 years. The investigation concluded at the end of the inquest on 30 th January  2026.  A jury returned  a shortform conclusion  of suicide along with a narrative that cited failure of staff on a mental health ward on 8 th December 2024 as factors that probably contributed to death, these were: The failure of the nurse in charge to authorise treatment under S.5(4) Mental Health Act 1983. The failure of a reviewing doctor to authorise treatment under S.5(2) of the Mental Health Act 1983. The jury also determined that the following factors possibly contributed to the death: The failure to increase the frequency of observations after Mr Zaman escaped the ward and then returned earlier on 8 th December 2024. The failure of staff on the ward to reappraise the level of risk presented by Mr Zaman on 8 th December 2024. Mr Zaman’s medical cause of death was determined as: 1a Immersion in water

Mansoor Zaman was a 27-year-old man with a history suicidality, substance misuse and a diagnosis of Emotionally Unstable Personality Disorder (“EUPD”). Following a period of inpatient treatment at the Newham Centre for Mental Health  (“NCMH”) following a suicide attempt, Mr Zaman was discharged into the community. On the evening of 6th of December 2024 The City of London Police attended to Mr  Zaman, sitting on the side of Southwark bridge over the River Thames. Mr Zaman  indicated suicidal intent. He was detained by police under Section 136 Mental Health Act 1983 and taken to a place of safety at Homerton Hospital where he tried to abscond and  was physically restrained. On the morning of Sunday 8th December 2024, Mansoor was admitted to Ruby Ward at the NCMH as an informal inpatient. At 14:33hrs Mansoor asked to be escorted outside to smoke, staff declined, he escaped through a fire exit. Staff followed him, persuaded him to return and he re-entered the  ward at 15:23 hours. A duty doctor was called to assess Mansoor. The consultation was shortened as  Mansoor became agitated. The Junior doctor considered that a S.5(2) Mental Health Act 1983 emergency authorisation was indicated which would allow both restraint and rapid  tranquilisation of the patient but deferred completing the decision to seek telephone  advice from the on-call specialist registrar. After the duty doctor assessment at 15:31, Mansoor assaulted a ward staff member. At 15:37hrs he walked towards the fire exit door and kicked it open and walked out. Staff did a ground and area search but could not locate him. At 16.46 on 8 th December 2024, a person believed to be Mansoor was observed [REDACTED]. At 18.27 on 8 th December 2024, staff at Ruby ward called police on 101 to report Mansoor missing. On 29th December 2024. The body of the deceased was recovered between Westminster bridge and Lambeth bridge

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.

1. The failure of nurses on the ward to instigate an authorisation  under S.5(4) MHA 1983 when Mr Zaman returned to the ward

after absconding on the afternoon of 8 th December 2024.

1. The failure of nursing staff on the ward to adequately document

observations and care decisions.

1. The failure of Trust staff to reappraise the level of risk

presented by Mr Zaman to himself and others in light of his  erratic behaviour on 8 th December 2024, specifically, a.  His escape from the ward by violently kicking the fire exit door. b.  His aggression toward the duty doctor during assessment. c.  His assault upon a member of ward staff.

1. His second escape from the ward in identical circumstances to

the first. The failure of Trust staff to re-assess the frequency  and quality of observations that Mr Zaman should be subject to  during the afternoon of 8 th December 2024.

1. The failure of the duty doctor to act decisively and impose an  authorisation under S.5 (2) MHA 1983 having been presented

with an agitated patient who had minutes before escaped from  the ward.

1. The dilatory response of staff on the ward to report Mr Zaman  as a missing person to the police, an action that did not happen

for almost three hours after it was known that he had  absconded.

1. The categorisation of the risk presented by Mr Zaman as of a  medium level by the nurse in charge when considering action  to be taken after he absconded.
2. The use of the police 101 number as opposed to the required

emergency 999 number to make the report.

1. The inadequacy of the Trust patient safety framework

investigation which neither sought the recollections of treating  staff, nor communicated the findings of the report to the same  staff.

In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.

th February 2026