An inquest has found that a "missed opportunity" to place a 19-year-old woman into a secure rehabilitation unit contributed to her death. Soviya Rajaratnam, from Kingston, died on September 9, 2021, after running away from escorted leave from a psychiatric hospital. Her family claims that South London and Maudsley (SLAM) NHS Trust considered it "too expensive" to place her in such a unit.
Inquest finds missed opportunity
At Croydon Coroner's Court, a jury concluded that consideration "should" have been given to long-term rehabilitation plans while Miss Rajaratnam was in hospital between May and June 2021. The jury foreperson told the court on Friday, September 18: "Soviya's death was possibly contributed to by the missed opportunity to admit her for locked rehabilitation in May to June 2021."
Dr Sohom Das, an expert forensic psychiatrist, said at the inquest that this missed opportunity "contributed materially" to her death. Miss Rajaratnam had been sectioned under the Mental Health Act and absconded during escorted leave. Two days before her death, she had been informed that she would be moved to a locked rehab unit, a long-term placement where patients can be detained and gradually recover.
Family's claims of cost concerns
According to the family's lawyer, Patrick Dunne, social worker Adrianna Lazdins suggested that Miss Rajaratnam should be admitted to a locked rehab unit during her detention in May to June 2021. Mr Dunne claimed that a manager in SLAM's community care team said in an email: "Regarding the locked rehab, it's very expensive, and SLAM will not pay for that." Mr Dunne described this as "rather shocking".
Assistant Coroner for London South Sebastian Naughton, summing up the evidence, said that Dr Das told the court: "Frankly, I'm confused why it was said it was too expensive - it's to be based on clinical representation and whether they need it."
Events leading to death
Miss Rajaratnam returned to hospital in August 2021 and was on a "general acute ward" at Bethlem Royal, a psychiatric hospital, at the time of her death. She had been diagnosed with paranoid schizophrenia, PTSD, emotionally unstable personality disorder, borderline learning disability, and had a history of substance issues.
The coroner stated that on September 7, 2021, Miss Rajaratnam was told that the plan was to move her to a locked rehab unit. Dr Das explained: "On September 7, news was given to her that changed something in her mind. She thought she was going to come out quite soon, then she was going to be detained in the long term. Instead of thinking she needs to jump through the hoops, she's thinking 'I don't know when I will be discharged'." He added that this "bad news" increased her "risk profile", and while escorted leave was appropriate, it should have been changed on September 6 or 7, 2021.
Both Miss Rajaratnam's mother and a social worker raised concerns about her reaction to the plan. The jury found that the clinician responsible for her care "should have had greater appreciation of the increased risk". The foreperson added: "The way the plan for locked rehab was communicated to Soviya on September 7 also possibly contributed to her death."
Final hours and cause of death
On September 8, mental health nurse Oluyinka Obisesan and care support worker Odunola Adewoye accompanied Miss Rajaratnam on escorted leave. She asked to smoke a cigarette, which was permitted off hospital grounds. Ms Obisesan stated that "They were either side of Soviya and as soon as they were outside the gate, Soviya ran away". She called the police just before 12pm that day.
Miss Rajaratnam was found dead the following day. Her medical cause of death was heroin and synthetic opioid toxicity. The jury found that the probable cause of death was drug use on September 9, likely contributed to by her mental ill health. A friend who found her, who was not named, said: "She had attended heavily intoxicated and was very loud. She had asked for drugs and money, but he didn't give her any. He left her in his flat at 1.30pm before returning at 4pm. He found her unresponsive, he couldn't find a pulse, he rang 999."
