The sudden death of an Ilford man with paranoid schizophrenia who collapsed in the shower in May 2021 was “likely” brought on by his high dose of anti-psychotics, the East London Coroners’ Court heard today. Glen Wemborne, 29, battled hallucinations for years after receiving a double diagnosis of schizophrenia and Asperger’s syndrome, at his worst suffering financial abuse from a shaman who sold him lotions at a time where he believed delusions about aliens, black magic, and creating the world.
Psychiatrist Dr Muhammad Bhenick told the inquest Glen’s “serious risk towards others” and “violent behaviours” – including threatening to stab his mum’s partner – required a strong dose of anti-psychotic drugs including amisulpride and sedative clozapine. This meant regular physical health checks and an annual ECG (heart scan) to stay on top of known side effects which include cardiac arrythmia.
After assaulting his support worker with a brick in 2009 he was convicted and institutionalised, but treatment and medication allowed him improve his life and he was enjoying working at a café by January 2020. Tragically, social workers recalled “he was doing well, doing work, paying his bills, not being aggressive” in the weeks before his death, but noted “he was upset he had not been able to live a life people in their 20s should”..
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Man didn’t show up for breakfast
In the months leading up to his death Glen repeatedly complained of “drowsiness” to his psychiatrist, saying he felt “like a vegetable” on the drugs. In response, Dr Bhenick revealed: “It was agreed if his mental state had stayed stable for the next few months a reduction of his amisulpride would be considered.”
The court heard how a change in his dosage from 600mg to 400mg, then back to 550mg was deemed “quite a big dose” by Dr Bhenick, but it did not “technically” constitute a “high dose” and therefore an heart scan was not urgent. In any case, Glen did not receive his annual ECG in January 2021.
GP Dr Arunan Thurairajan said the need for the scan was a “grey area”, but conceded it should have been done. He said: “In short in normal circumstances we would have been looking to do an ECG, the plan was to do an ECG, but in this case the ECG has not happened.”
On May 27, 2021 Glen went to bed early at his supported accommodation Endsleigh House in Ilford – he would usually rise early for work. But, care staff were alerted to an issue when they did not see him at breakfast the next morning. Care worker Anwar Takun went to his room and “heard the shower running but could not hear him”. Unable to open the door with a coin he went to get a screwdriver.
Found ‘covered in shower curtain’
Upon opening the door with another colleague, he found Glen in the bath “covered in the shower curtain”. In a panic, Mr Takun rang the home manager who told him to “put the phone down and ring 999”.
The inquest heard how the emergency call-handler “correctly triaged the call” but the London Ambulance Service “admitted criticisms” with some of her advice. LAS quality assurance manager Ms Lyn Sugg said: “She should not have said can you get him out of the bath, she should have asked can you do CPR. The difficulty is the lack of assertion and urgency in what she did.” The call handler is expected to take retraining.
Glen’s mum Marian West took the opportunity to question the LAS over the call, asking: “Do you agree it was not too late to carry out CPR?” Ms Sugg replied that “she should have given the instruction”, adding: “But I can’t say if that would have had any impact.”
Paramedics arrived within six minutes at around 6.36am but were unable to save Glen, determining he had been dead at least half an hour. No resuscitation was attempted and police declared his death unexplained but not suspicious.
Coroner Dr Shirley Radcliffe concluded Glen died of sudden arrhythmic death syndrome and schizophrenia on May 28, 2021. She said: “He was a paranoid schizophrenic that required him to take high doses of anti-psychotics. It’s likely his death was related to his high dose of anti-psychotics which are likely to cause cardiac arrythmia.” Referring to the missed ECG, she said “we can’t say” if it would have shown “any abnormalities or if it would have been normal”.
A ‘truly special person’
Speaking after the inquest, Marian West said: “Glen was a truly special person who lost his life at 29 at his care home in Ilford. His premature and unexpected death came as a massive shock to us, his devoted family.
“Glen and I repeatedly requested that the medication be reduced in the months leading up to his death as Glen was suffering severe symptoms that affected his health and wellbeing. Glen never complained even though he felt unwell. Glen was desperate to have the medication reduced and his wish was to come off the medication.
“After Glen’s death I found out that sudden death due to arrythmia is a rare but known risk due to prolonged use of antipsychotic medication. This came as a huge shock to me and I wish I had been informed about this by the mental health team as I would have insisted that the dosage was reduced and I would have got a second medical opinion on his prescription.
“Glen was a kind, gentle and wonderful son, brother, and nephew. He was always grateful for everything and everyone in his life. Glen had made very good friends with his employer at a local coffee shop where he worked part time and was best friends with his colleagues. Everyone at the coffee shop and customers alike loved Glen. Glen had a wonderful and unique sense of humour. We miss his laughter and cheeky ways.
“To lose Glen is so heart-breaking. Saying farewell to Glen is the hardest thing we ever had to do. We are grateful for all our wonderful memories every moment we shared with him. We will never get over losing Glen.”
Glen’s family’s lawyer, Nina Ali said: “Glen’s death, and the circumstances surrounding it, have been incredibly difficult for his loved ones. We can only hope that some valuable lessons will have been learnt from the circumstances of Glen’s death and that tragedies such as this can be avoided in the future.”
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