Inquest finds multiple ‘gross failures’ led to man’s death at Whipps Cross A&E

This week an inquest concluded there were multiple gross failures to provide basic care to John Cushion before he died.

John, who lived in London Borough of Redbridge, experienced a deterioration in his mental health from 3 July 2024. On 18 July 2024, after discovering John had attempted to take his own life, his wife Francesca Cushion called 999. Paramedics took John to hospital for a physical health check and mental health assessment.

After arriving at the Whipps Cross A&E Department at around 2pm on 18 July 2024, John and Francesca were forced to wait in a corridor until the evening. John was then assessed by a nurse. He was also assessed by a doctor who concluded he needed a mental health assessment. That assessment should have taken place that evening but due to a failure in communication and missed opportunities to chase up the referral it was not actioned until the following day.

When assessed by the mental health team the following day, John reported that he was still feeling “100% suicidal”. The mental health team told A&E staff that John needed to be immediately put on 1:1 observations (in sight of a member of staff at all times).

Another mental health team came to review John a short while later, and it was decided that John would be admitted to a specialist mental health hospital and that for his own safety he should not be allowed to leave A&E. John was told that he would need to wait in A&E for a mental health bed to be available.

On the evening of Friday 19 July 2024, John was found unresponsive in his cubicle. There were attempts to resuscitate him, but these failed.

An inquest into John’s death was held at East London Coroner’s Court, Walthamstow, from 11 May 2026 to 18 May 2026.

Area Coroner Nadia Persaud found multiple gross failings in John’s care including:

• The collective failure by nursing staff to ensure John was on one-to-one observations;
• The failure to check on John for 50 minutes before he was found unresponsive, despite it being noted during this time that he was in his cubicle alone with the lights off and the curtains drawn;
• The failure to remove from John items with which he could harm himself. 

She found there was a “clear and direct causal connection” between these failures and John’s death.

The coroner also raised concerns about the “honesty and integrity” of some of the evidence she heard. She found that she did not consider the account of one member of staff from Barts Health NHS Trust to be “truthful and accurate”. She told the Trust to investigate her concerns further and to report back to the court and John’s family.

In her evidence to John’s inquest, his wife of almost 30 years, Francesca, described him as being devoted to her and their two children and said that after many years of hard work she and John had been looking forward to a long retirement together and to seeing their children embark on their adult lives.

John’s family were represented by Sophie Wells, a human rights solicitor at Leigh Day, and barrister Matthew Hill of 1 Crown Office Row.

Following the conclusion, Francesca Cushion said:

“I am very grateful to the coroner for the care she has taken when investigating John’s death. I agree with her findings about the failings at Whipps Cross Hospital and I hope that lessons have been and will continue to be learned to ensure no other family has to go through what I and my daughters have over the last two years.”

Leigh Day human rights team solicitor Sophie Wells, who represented the family, said:

“Even in the context of the pressures on A&E departments and the mental health system, the scale of the failings in John’s care which the inquest uncovered, both in number and gravity, is shocking.

“I am pleased for John’s family that they now have a clearer understanding of what went so wrong for John, and that the coroner has recognised that a number of the failings met the very high threshold of neglect.

“I wish to pay tribute to the dignity of John’s family and friends, and I share their hope that the changes made since his death, and further reflection by those involved in his care, will protect vulnerable individuals like John in the future.”