Watchdog tells Haringey mental health trust to improve months after criticism over Archway Bridge deaths

Inspectors have told Haringey mental health chiefs to improve services, months after the families of two men who jumped to their deaths from Archway Bridge condemned the care their loved ones received.

Jonathan Culverwell-Landsberg, 33, and Troy Brown, 32, who suffered from paranoid schizophrenia, both fell from the bridge over Hornsey Lane in Archway last summer.

The men were under the care of the Barnet, Enfield and Haringey Mental Health NHS Trust, which last week was heavily criticised by independent health regulator the Care Quality Commission (CQC) for “failing to meet national standards” in its management of patients’ medication.

A report by the CQC found that there were gaps in the trust’s records, meaning that patients may have missed some of their doses.

Mr Culverwell-Landsberg and Mr Brown failed to take their medication in the months leading up to their suicides and their families said no one from the trust checked to see if they were taking it.


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Mr Culverwell-Landsberg’s mother, Ceidre Culverwell, 62, of North Hill, Highgate, said: “If Jonathan had taken the medication he was supposed to be taking, maybe he could have been saved.”

An inquest into Mr Brown’s death at Barnet Coroner’s Court last month ruled that neglect in his care contributed towards his death.

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Danielle Brooks, Mr Brown’s partner, said: “They let him down,”

The 26-year-old mother of his two young children, added: “A care plan had been put in place but it wasn’t implemented.

“When we heard the inquest verdict it was a relief, but it was upsetting because if the trust had just done its job, he might still be here.”

The CQC’s report also found that staff members were not supervised regularly and scheduled visits to patients were often cancelled or did not take place at the expected time.

Mary Sexton, executive director of nursing, quality and governance at the trust, said: “The quality and safety of care we provide to our patients is our number one priority and, as the CQC inspection found, the majority of people have a very positive experience of care from our crisis and home treatment teams.

“However, on this occasion the CQC found that in certain areas we were not reaching the consistently high standards which we always aim to achieve, which we accept and regret. We have taken immediate action to make sure that the problems identified by the CQC are addressed so that patient care and safety is not compromised, including: introducing weekly pharmacy audits for the home treatment teams in all three boroughs to make sure that medicines are being handled and stored in a safe and secure way and all information is recorded accurately, ensuring additional medicines management training for all staff involved in the administration and supervision of medications and ensuring all staff receive regular professional supervision.

“We are committed to being a learning organisation and will continue to use the feedback we receive from staff, service users and regulators to improve the care and services we provide to our local community.”

“We would like to reiterate our condolences to the family of Mr Culverwell-Landsberg and to Mr Brown. The trust always strives to offer the highest standards of treatment, care and support to our patients and their families and carers and we would be more than happy to discuss this specific case with the family.”

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