The widow of a former soldier is calling for lessons to be learnt after a jury inquest found that there were failures in the hours before his death while he was sectioned at a Peterborough centre.
Nepal-born Prem Rai, 39, was a Ghurkha soldier for 18 years before embarking on a career change and training as a butler. However, during his training Prem was admitted to Chelsea and Westminster Hospital and referred to mental health services in July 2016.
Over the following weeks, Prem was kept under medical observation at Ward Oak 2 Cavell Centre, Peterborough. On the morning of 19 August, 2016, Prem was found unresponsive in his bed with no obvious sign of the cause of his death.
Following Prem’s death, his widow Chandra Rai instructed medical negligence lawyers to investigate the care Prem was given by the Cambridgeshire and Peterborough NHS Foundation Trust - with an inquest revealing failures at the centre.
Chandra, who has a nine-year-old son with Prem, said: “While myself and the family hope that lessons can be learned from the issues which have been highlighted to ensure that other lives can be spared, Nothing can bring my husband and my son’s father back.
“It will forever be a source of great distress that, if things had been done differently, Prem’s death could have potentially been prevented.
“I do not want any other family to suffer like we have suffered or like my husband suffered.”
An inquest into his death was held at Peterborough Town Hall, where the jury found there that there were failures in the manner in which observations were performed prior to Prem being found unresponsive.
The jury also found that it is probably that Prem had died several hours prior to his recorded time of death due to the fact that rigor mortis was present when his death was confirmed by the paramedic at 9.12am.
Over the course of the inquest, the findings of a Serious Incident Investigation Report, conducted by Cambridgeshire and Peterborough NHS Foundation Trust in the wake of Prem’s death, were heard.
The report concluded that the senior management team at Cavell Centre needed to develop mechanisms to ‘have a greater oversight of the conduct of the core clinical tasks and governance of the ward’. The report identified a number of influencing factors including a lack of adherence to guidelines, policies and procedures; a lack of evidence of communication between staff and environmental disruption.
Gurpreet Lalli, a specialist medical negligence solicitor at Irwin Mitchell’s Cambridge office representing Chandra, said: “This is a sad case and, over a year later, Chandra is still trying to come to terms with the loss of her husband and her child’s father.
“Chandra has been awaiting the outcome of the inquest for a long time and she, along with the family, is relieved to have some answers at last. It has been their wish that lessons can be learned from Prem’s death.
“The family will always believe that earlier identification of distress by staff at the Cavell Centre could have prolonged, or even saved, Prem’s life by transferring him to Peterborough City Hospital for emergency treatment.
“The Serious Incident Report and Inquest have revealed some areas of concern and we hope that these will be addressed as soon as possible to improve patient safety.”
The coroner recorded a narrative verdict at the end of the inquest.