Agenda item

South London & Maudsley NHS Foundation Trust - Inquest into the death of Sean Rigg

(Report no. 135/12-13)


Contact for details: Elaine Carter, Lead Scrutiny Officer, 020 7926 0027,


(Report no. 135/12-13)


Marcia Rigg, sister of Sean Rigg, addressed the Committee, stating that she had worked closely with the mental health carers of her brother over a number of years but had been disappointed by the way in which Sean had been managed in recent years. For example, SLaM had allowed Sean to travel frequently to far away destinations and had often not take his medication. On the day of Sean’s death, he had not taken his medication and this has inadvertently caused his death. She expressed her disappointment that SLaM had not informed her that Sean had not taken his medication and noted that better systems should be put in place to ensure that communications channels stayed open even when permanent staff were on annual leave, as had been the case at the time of Sean’s death. The inquest into the case had found that SLaM had contributed to Sean’s death and it was vital that proper procedures and systems were put in place to avoid similar cases in the future.


Matilda MacAttram from Black Mental Health UK asked that it be put on record that the inquest into Sean Rigg’s death had recorded that he had died at Brixton Police Station rather than at Kings College Hospital. She also noted that concerns flagged up with SLaM following the Sean Rigg case were not being addressed through community engagement work with BMH UK as promised and remained outstanding.



The Chair thanked Marcia Rigg for attending the meeting and for campaigning for years on behalf of Sean to ensure that lessons were learned from this tragic case. He asked how further progress could be made to avoid similar incidents in the future.


In response to queries from Members, representatives from SLaM made the following comments:


  • Further learning was required around the interface between SLaM and the Police, with a view to improve both the relationship between the two agencies and communication in difficult situations like that involving Sean Rigg. 
  • A serious incident had occurred the previous week at the Bethlem involving two patients at SLaM taking other patients and staff hostage. The police had been called for support but the incident had been managed well by staff at SLaM and the police did not get involved in the incident. This demonstrated that improvements had already been made to the way in which the Police and SLaM were working together and the team which was called in to deal with such situations were adequately trained.
  • Since the death of Sean Rigg, a zoning placement had been implemented within SLaM and this meant that any individual which was placed in the red zone was perceived to be high risk and would be assessed daily by a psychologist. However, it was recognised that this should have been introduced much earlier as this would have assisted in a quicker and more effective assessment of Sean Rigg.


The Chair thanked all for attending the meeting, noting that this was a very important issue and urged Members and officers to ensure that continuing improvements were made to the process and treatment of mentally ill people in the borough. He finally asked the Marcia Rigg and Matilda MacAttram from Black Mental Health UK attend the forthcoming full Council meeting to address Councillors on this important issue.


As follow up actions he proposed that:


·        A recommendation be made to the Health and Wellbeing Board that it should look at mental health and BME issues across the piece

·        SLAM and partners work with Cllr Cameron, Cabinet Member for Equalities and Communities, around equalities issues

·        Marcia Rigg and Matilda MacAttram from Black Mental Health UK be invited to attend the forthcoming full Council meeting to address Councillors on this important issue.

·        A note of the meeting be sent to Monitor

·        That the principles of openness and transparency should be endorsed by health trusts. It is healthy for the health overview and scrutiny committee to be informed of instances such as occurred on 1 October 2012 and all should work towards a protocol on sharing information.




(1)   To note the learning underway and delivered from this incident.


(2)   To note the joint partnership programme of activities underway to support future progress.


Supporting documents: