Coroner slams 'scandalous' failures after woman laid dead for two years

East London Coroners Court with Lillian John-Baptiste inset

A coroner hit out at the 'scandalous state of affairs' which meant vulnerable mental health patient Lillian John-Baptiste (inset) laid dead for over a year before any state agencies thought to check on her welfare - Credit: Archant / Met Police

A council and a mental health trust may face formal action after a woman laid dead for over a year before anybody went looking for her.

Coroner Graeme Irvine criticised “shocking” failures in the care of Lillian John-Baptiste, who is believed to have died in late 2019, aged 73.

Her body was not discovered in her flat at Westland House, Rymill Street, Canning Town until early 2022.

At her inquest, Mr Irvine said he worried that unless services improved, other vulnerable people could suffer the same fate.

He said Newham Council and the East London NHS Foundation Trust (ELFT) had also failed to take her "harrowing" death seriously enough.

Both the local authority and ELFT sent their condolences to Mrs John-Baptiste's family, with Newham Council saying it is "fully committed" to addressing the concerns and ELFT "reviewing what can be learned" from the case.

Lillian John-Baptiste

An inquest heard Lillian John-Baptiste moved to England from St Lucia at age 15, working as a singer, a model and a writer before becoming a nurse in Stratford - Credit: Amanda Alexander

“It’s a scandalous state of affairs that a vulnerable person in our society can lie undiscovered in her home address for such a long period of time that she becomes mummified," he said.

“What’s worse is that this was a person who was clearly on the radar of a number of branches of the state."

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He said processes had "singularly failed in this tragic set of circumstances.”

The death is now the subject of a safeguarding investigation.

ELFT

An inquest heard Mrs John-Baptiste had schizoaffective disorder.

Whilst broadly compliant with treatment, she suffered periodic relapses during which she was known not to properly care for herself.

But when she failed to answer phone calls from ELFT in late 2019 and early 2020, it struck her off as a patient instead of investigating.

Evidence suggested she may have still been alive when the calls began, but was likely dead by the time she was struck off.

Consultant psychiatrist Dr Azad Cadinouche testified that "with hindsight”, ELFT should have “taken thorough steps” to flag her disappearance to other agencies, including the police.

Mr Irvine said ELFT had also “failed in its governance” by not launching an internal investigation into her death.

He gave ELFT 28 days to persuade him not to raise formal concerns, adding: “Arguably, I’m being rather generous.”

ELFT headquarters in Aldgate

Coroner Graeme Irvine gave the East London NHS Foundation Trust (ELFT ) - whose headquarters in Aldgate, central London, are pictured here - 28 days to persuade him not to write a formal report into failures by the mental health service - Credit: Google Streetview

Newham Social Services

Newham Social Services had also stopped checking on Mrs John-Baptiste.

Her tendency for “self-neglect”, linked to her mental health, meant she had been visited by carers.

But in 2018, when she said she no longer wanted help, she was deemed to have the capacity to make that decision.

Social services did not contact her again until 2021, when checking on vulnerable residents during the pandemic.

“Mrs John-Baptiste was somebody who had a very problematic mental health background – a long and enduring illness since 1977. She was just the type of person whose capacity was likely to fluctuate,” said Mr Irvine.

Yet, he said, there “doesn’t seem to have been any social curiosity” about her wellbeing after 2018.

“Were it not for the Covid welfare actions that were undertaken, what guarantee do you have that Mrs John-Baptiste would ever have been discovered by the London Borough of Newham?” he asked council team manager Belinda Berry.

“I’m going to be honest,” she replied. “I don’t think we would have known.”

He also gave Newham Council 28 days to persuade him not to raise formal concerns, again describing his stance as “generous”.

Westland House, Rymill Street, Canning Town

Lillian John-Baptiste's mummified body was found at Westland House, Rymill Street, Canning Town in February 2022 - but she had likely been dead since late 2019 - Credit: Google Streetview

Concerns

Mr Irvine called the case “a damning indictment of society at large”.

“It’s hard for me to understand how a vulnerable person of the age, standing and vulnerabilities of Mrs John-Baptiste could have been allowed to go for such a long period of time, unattended,” he said.

“It’s all the more curious when we know that she had come to the attention of social services and the local secondary mental health trust.

“I don’t say that Mrs John-Baptiste's life could have been saved... But it might be that there’s another Mrs John-Baptiste out there who is vulnerable, is in distress, and better communication between the mental health teams and the local authority could result in changes of procedures and policies that could improve safety for other vulnerable persons.”

East London Coroner's Court, Ripple Road, Barking

At an inquest into Lillian John-Baptiste's death - held at East London Coroner's Court in Ripple Road, Barking - coroner Graeme Irvine said the details were 'harrowing' and 'shocking' - Credit: Charles Thomson

Responses

ELFT said it sent "sincere condolences" to Mrs John-Baptiste's family.

“Patient safety is a foremost trust priority and we are thoroughly reviewing what can be learned from the death of Mrs John-Baptiste," it added.

Jason Strelitz, Newham Council’s corporate director of adults and health, also expressed condolences.

"We have been cooperating fully with the coroner’s office and the independent safeguarding adults review, and are fully committed to addressing any lessons learned or insights gained," he said.