Inquest jury concludes multiple failures possibly contributed to the death of Benjamin ‘Ben’ Brown

Mirren represented the family of Benjamin ‘Ben’ Brown, whose inquest took place between 15 September 2025 and 25 September 2025 at the Inner North London Coroner’s Court. The jury heard that Ben, a talented musician who was sectioned at Homerton Hospital, had been given unescorted leave in the weeks leading up to his death and had gone missing while on leave on 15 December 2021, ultimately dying by suicide.

The jury also heard that Christmas was a risky time for Ben, who believed he was a failed messiah and was known to mask his symptoms. On 8 November 2021, Ben’s Responsible Clinician had unexpectedly gone on long-term leave, resulting in his care being managed by various clinicians. On 25 November 2021, a decision was made to grant Ben unescorted leave for the first time for 30 minutes twice per day. This was increased roughly every week, and, on 14 December 2021, Ben was granted 6 hours unescorted leave per day. Ben’s partner, James Ferguson, and Ben’s family were not consulted about these decisions. The East London NHS Foundation Trust, which runs Homerton Hospital, was not able to provide any section 17 leave forms, sign-in and sign-out sheets, or records of Ben’s mental state prior to going on leave relating to this time.

On 15 December 2021, Ben left the hospital at an unknown time, likely around midday. James found Ben at his flat at 6pm, but Ben left around 8pm saying that he had to return to the hospital. When James realised Ben had not returned, hospital staff told him to contact the Metropolitan Police in contravention of the Trust’s missing persons policy, which required the hospital to take immediate action following Ben’s abscond. Hospital staff did not tell the police until about 19 hours later that Ben was high risk, and the police did not categorise Ben as a high-risk missing person until around 5pm on 16 December 2021. A subject matter expert for the police told the jury that there was sufficient evidence at the outset for officers to classify Ben as high risk.

The jury concluded that the following failures possibly contributed to Ben’s death:

  • Ben’s ability to mask symptoms was inadequately appreciated by his treating clinicians.
  • The views of Ben’s partner and family were not properly sought and considered.
  • There was a significant failure in the record keeping, which affected the care given to Ben, and his safety.
  • It was not clinically appropriate to increase Ben’s unescorted leave.
  • The absence without leave policy was not followed correctly.
  • Ben should have been categorised as a high-risk missing person earlier.

The jury also found that aspects of Ben’s treatment in the community, prior to him being sectioned, had been inadequate. A decision as to whether the Coroner will make a PFD report in this case is awaited.

Mirren was instructed by Christina Juman of Deighton Pierce Glynn solicitors.

More detail about Ben’s case, provided by the family’s solicitors, Deighton Pierce Glynn, can be read here: https://dpglaw.co.uk/inquest-into-death-of-benjamin-brown-concludes/ 

 

Related Barristers: Mirren Gidda

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