Mr Mandrik was 37 years old when he died in September 2023. He had paranoid schizophrenia and was acutely vulnerable.
Having been detained under the Mental Health Act 1983 for several months, Mr Mandrik was required to be under four observations per hour. On the day of his death, no observations were carried out for a period of more than three hours. During that time, he died by suicide.
Following an inquest, the jury concluded that inadequacies in the system for allocating observations, together with the failure to conduct those observations, contributed to Mr Mandrik’s death. In the circumstances, the jury concluded that this failure was sufficiently gross that it amounted to neglect.
Jack Boswell represented Mr Mandrik’s niece at the inquest, instructed by Gold Jennings.