Inquest concludes into death of Bushey man at mental health hospital

Simon Cohen, 29, from Bushey, died after he was found unwell by staff at Kneesworth House Hospital near Royston in north Hertfordshire in June 2017.

An inquest held this month heard Simon, who changed his name in 2016 to Alex Nova but was still known to family by his original name, had taken a fatal amount of the drug MDMA, known as ecstasy - although the coroner was unable to determine where the drug had come from.

Simon was admitted to Kneesworth, which is run by The Priory Group, on June 16 after being detained under the Mental Health Act following a diagnosis of paranoid schizophrenia complicated by drug use.

Five days later, it was agreed Simon could be given fixed free time slots but be accompanied by a member of staff. On the morning of June 27, he was accompanied by a healthcare worker to have a cigarette.

On the afternoon of June 27, staff noticed Simon’s eyes were rolling. After being informed by another patient he was unwell, an ambulance was called just before 3pm but Simon’s condition rapidly deteriorated and he died later that afternoon.

Simon’s mother Nozalie Shuter instructed public law and human rights lawyers at Irwin Mitchell to find answers about her son’s death.

Following the inquest in Huntingdon, Ms Shuter said: “It’s almost impossible to find the words to describe the hurt and pain our family feel following Simon’s death.

“Simon had struggled with mental illness and we hoped that going into Kneesworth House would allow him to receive the care he needed.”

Simon Cohen. Credit: Family handout

The family’s lawyer Sophie Farrah said: “Not knowing all of the facts about what happened to Simon has made trying to grieve for him all the harder. The one question that remains unanswered is how he managed to obtain and take MDMA whilst within a locked rehabilitation ward at Kneesworth Hospital.

“It’s vital people with mental health problems receive the best level of care at all times. It is fundamental that lessons are learned to improve patient safety.”

Following Simon’s death, The Priory Group, which is said to have been aware of his drug use , strengthened safeguarding procedures, including installing CCTV and undertaking more robust drug screening and searches.

Ms Shuter said: “We remain devastated at the way in which Simon died and despite being in a place where he was supposed to be safe, he had managed to come into contact with drugs.

“We accept that changes have been made but unfortunately it is too little too late for Simon and for our family.”

A Priory spokesperson said: “We would like to extend again our sincere condolences to the Cohen family for their loss. The jury found no criticism of the care provided to Simon, and could not conclude how he accessed the drug.

"This was consistent with our own internal investigation, which was shared with the court and the family a number of years prior to the inquest.

"The court heard of the continuous improvements made at Kneesworth, to ensure we carry out appropriate searches to balance the patient’s rights with the desire to keep them safe. The coroner was satisfied that we are doing all we can to manage those risks."