Amy Clarke appears on behalf of Mental Health Trust in complex Article 2 inquest

16 December 2022

Amy Clarke appeared on behalf of the East London NHS Foundation Trust at the inquest touching into the death of Desmond Maddix.

Mr. Maddix was an inpatient on an acute psychiatric ward at the time of his death in 2017. He had a complicated history of mental illness, and at the time of his last admission was particularly unwell. Another patient, a drug user, procured heroin during a period of unescorted leave, and tragically administered it to Mr. Maddix against his will. That individual was subsequently convicted of manslaughter.

The inquest examined Mr. Maddix’s mental health history and his treatment during his final admission, including the management of medication and his status as a particularly vulnerable individual on a busy and demanding ward. In addition, the challenge of managing informal patients permitted to take unescorted leave was explored, as were the processes for risk assessing periods of leave and carrying out searches of patients upon their return.


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