Failure to provide James Stow with a one-to-one mental health nurse “possibly contributed” to his death, inquest jury finds
20 March 2026
Garden Court North’s Camille Warren represented James Stow’s sister during the inquest at South London Coroner’s Court (pictured). Credit: Glen Berlin / Shutterstock.
The inquest into the death of James (‘Jim’) Stow at South London Coroner’s Court has found that the South London and Maudsley NHS Foundation Trust’s failure to provide him with a one-to-one mental health nurse “possibly contributed” to his death.
At the time of his death, Jim was under a Mental Health Act section at Rosa Parks ward at Lambeth Hospital. On 18 September 2021, he absconded from Rosa Parks ward whilst on unescorted leave.
A few hours later, Jim was found by members of the public having physically collapsed. He was taken by ambulance to Croydon University Hospital (CUH) where he was treated for sepsis and cardiogenic shock.
When CUH realised that Jim was a patient under section at Rosa Parks ward, Rosa Parks ward did not provide an escorting one-to-one mental health nurse.
Jim subsequently absconded from CUH on 25 September 2021.
The inquest jury’s findings
During the inquest, the Trust accepted that there was a failure by them not to provide Jim with a one-to-one mental health nurse from 19-25 September 2021, contrary to their duties under the Mental Health Act.
On 25 September 2021, Jim was not deemed ready and fit for discharge or transfer to Rosa Parks ward. He was scheduled for further investigation into possible underlying or pre-existing medical conditions.
Jim’s sister was never made aware that her brother had been a patient at Rosa Parks ward nor that he had absconded from hospital.
Jim’s body was found at approximately 15:30pm on 18 November 2021, at a makeshift encampment near Long Lane, Croydon. Due to decomposition, the cause of his death remains unascertainable.
Garden Court North’s Camille Warren was instructed by Farleys Solicitors’ Kelly Darlington to represent Jim’s sister during the inquest, which opened on 18 August 2023.
Following the inquest, Jim’s sister Claire said: “My brother Jim’s needs and safety were overlooked by the system when he most needed help. I’m so, so sorry that he was let down by a system that is meant to help and protect us when we are at our most vulnerable. I will always remember him for his quirkiness, his intelligence, and our shared history – me and him, as kids against the world. Jim chose me as the person closest to him, and that opportunity to support and care for him was taken away. The inquest did not provide all the answers I had hoped for, but I will continue to fight to ensure justice for Jim and his family. Not being able to say goodbye and not being there for him in his final moments is a heartbreak I will carry forever.”
Kelly said: “Jim’s sister has had to endure a long and painful process in finding out all the facts surrounding her brother’s tragic death – some of which she will sadly never know. The Jury’s conclusion highlights the missed opportunities that could have ensured Jim’s was better protected at a moment in time when he was at his most vulnerable and possibly prevented his death – something we will never know. The South London and Maudsley Trust have made a number of changes since Jim’s death including staffing and importantly one-to-one escorting nurses. It is hoped further learning is taken away from the inquest to ensure policies and procedures are sufficient to prevent further deaths.”
For further information, please contact Alex Blair, Communications Manager at Garden Court North Chambers: ablair@gcnchambers.co.uk
