Hostel failings are revealed at inquest into death of homeless man
Coroner told of staffing crisis and use of agency support workers
04 December, 2016 — By Alina Polianskaya
Gregor Ribeiro had been living at the King George’s Hostel
A HOMELESS man who went missing from a psychiatric hospital was found dead in a hostel two days later, after staff failed to inform police he was there.
A four-day inquest at the Royal Courts of Justice this week into the death of Brazil-born Gregor Carvalho Ribeiro, 43, revealed a number of failures at the King George’s Hostel in Victoria, run by Riverside Group. The inquest heard how a staffing crisis at the hostel led to two agency support workers, with “little or no experience” there, manning the reception to the building, which has 68 rooms for former rough sleepers recovering from drug or alcohol addiction.
When police attended the hostel they were told Mr Ribeiro was not there, although CCTV footage showed him being buzzed in to the building earlier that day.
Mr Ribeiro, who had been diagnosed with schizo-affective disorder, was living in the hostel in July 2015 when he was sectioned to Gordon Hospital in Bloomburg Street.
During bad spells, he could become “aggressive” and “agitated” but despite some “fluctuations” his condition had improved and he was allowed to leave the hospital unescorted for two hours at a time, the inquest heard. On October 31 2015 he failed to return.
The inquest heard how hospital staff searched their grounds before calling the hostel and being told he was not there. Police searched the hospital. Later, at the hostel, they were told he was not there and had not been seen that day. PC Victoria Emsley told the court: “Both staff appeared quite confident that they had not seen him.”
PC Ben Guerin added: “They hadn’t pointed out at any point that they were new to this building… if that had been raised I might have explored other options.” He said he had “no reason to suspect” that Mr Ribeiro was in his room at the hostel.
Agency worker Deborah Salako, who was working with Lorraine Allette, said she could not remember full details of what happened that day but neither had known Mr Ribeiro.
The inquest heard that a combination of half-term, staff off sick, and another staff member being “awol” had created a problem that day.
Former team-leader Gina Sollazz said: “I tried all over London to get locum cover and there was no one available.”
Mr Ribeiro was found dead by a member of staff on November 2. Medical reports showed he had a number of drugs in his system, including heroin and cocaine. A syringe was found by his side. The cause of death was drug intoxication.
In her summing up, assistant coroner Dr Shirley Radcliffe said an investigation accepted that “insufficient planning led to inadequate staffing” on October 31 and that they had left agency staff on duty on that day with “little or no experience” at that hostel.
She said the company, Riverside, had addressed this by ensuring there must now be “at least one regular, experienced member of staff” present on each shift.
The jury returned a verdict of non-dependent drug abuse, and concluded: “Liaisons between the hospital and the wet hostel could be improved, though this didn’t cause his death.”
The coroner extended her “deepest condolences” to the family of Mr Ribeiro who had been in the inquest throughout “what must have been a very painful experience”.