Linden Centre: Jayden Booroff's abscond risk not recorded - inquest
A 23-year-old man who died after fleeing a mental health unit was not properly recorded as being an "absconding risk", an inquest heard.
Jayden Booroff absconded from the Linden Centre in Chelmsford, Essex, on 23 October 2020.
Patient safety investigator Paul Binyon told Essex Coroner's Court that written care notes showed he was an "absconding risk and an impulsivity risk".
Jurors heard this was missing from the SBAR electronic forms used by staff.
Mr Booroff, described as a talented musician, had been sectioned twice at the point he left the Linden Centre's Finchingfield Ward shortly after 19:45 BST.
His body was found near Chelmsford railway station about two hours later.
quest heard he had a history of undiagnosed mental health issues and was being given anti-psychotic medication.
Mr Binyon's serious incident investigation, on behalf of the Essex Partnership University NHS Foundation Trust, noted that staff observations of Mr Booroff were reduced two days before his death, from four times per hour to once per hour, which did not follow a "detailed plan".
"The heightened level of engagement leading to the incident may have given opportunity to detect behaviours, such as an unusual interest in exit routes, which may have indicated an impending attempt to abscond," he said on Thursday.
urt was told a nurse tried to "grab" Mr Booroff as he fled the unit, but that she had left her Pinpoint security alarm, used for alerting colleagues, in her car after arriving late to her shift.
report outlined nine similar incidents between 2017 and 2020 where inpatients "tailgated" staff out of unclosed doors.
"Lessons learnt had not been completed [on incident forms] leading the investigation to find that risk tolerance had been bound in favour of accepting the inevitability of absconding," said Mr Binyon.
"There were missed opportunities to learn from patient safety incidents."
matron at the time of Mr Booroff's absconding previously told jurors that staff would always discuss what "they've learnt" from each incident.
wo-week inquest is due to conclude on Friday.
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