Ealing Hospital Reviews Procedures After Patient Suicide

Changes made after death of 21-year-old

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Cygnet Hospital


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A private hospital in Ealing has reviewed its communication procedures after the death of one of its patients.

Veterinary assistant, Lisa Inkin, 21, suffered from anorexia and died last April after jumping in front of a tube train at Victoria station. She was being treated at Cygnet Hospital on Corfton Road in W5 because of a lack of beds available in Kent, where she lived.

On the evening before her death, a friend had phoned the ward at Cygnet to warn that Lisa was suicidal, no action was taken that night, and Lisa’s mother, Sherry, was not called until the following morning – when the 21 year old had already left home to return to the hospital. Sherry believes the tragic death could have been avoided.

Read the report here.

Cygnet hospital has offered condolences to the family and say staff were devastated to hear of Lisa's death.

In a statement they say:

“A friend of Lisa’s and former patient contacted the hospital the night before her death. This was recorded and dealt with by the Ward Manager who contacted the mother and spoke to Lisa the next morning, as well as speaking to the police to alert them to our concerns. The Coroner commented that Lisa may have been planning her death for a little while and even if she had been contacted may have continued to do so.

“A response to the Coroner is due by 10 April but several changes have already been made. Improvements include:

•         a review and reminder to all staff of the importance to escalate information;

•         shortened phone divert time to less than 30 seconds;

•         a cordless phone to ensure the phone is with a member of staff at all times;

•         the phone now bounces from one ward to the other if not picked up;

•         service users on leave are to be contacted every 24 hours.

“We have taken account of learning points and will carry out a full investigation as to the recording of information received about patients and the logging of telephone calls to the Unit and will write to the Coroner as requested to ensure we continue to drive forward high quality standards throughout the hospital.''


In February 2013, Cygnet Hospital Ealing was awarded Quality Network for Eating Disorders Accreditation, one of only five national eating disorders services to achieve ‘excellent’ accreditation by the Royal College of Psychiatrists.



12th March 2014