Staff at a hospital in Edgware failed to make regular checks the night before the death of a mentally ill musician and hospital volunteer, an inquest has heard.

On July 18 2015, Ben Brown was voluntarily admitted to Edgware Community Hospital and transferred to the Psychiatric Intensive Care Unit, Avon Ward, on July 19 after being sectioned under Section 2 of the Mental Health Act

At 8.51am on July 25, a nurse went to Mr Brown’s room to find that he was blue, not breathing and with no pulse after suffering a cardiac arrest.

The coroner at an inquest into his death concluded Mr Brown died of "natural causes".

Reports emerging from the inquest into the 35-year-old’s death revealed regular hourly and 15-minute checks through the night were not carried out by staff.

The last written observation of Mr Brown said he was asleep at 8.30am but the healthcare assistant who wrote it revealed at the inquest the observation was false as they had filled it in as rushing to another ward to feed patients.

Examples of the hospital’s and Barnet, Enfield and Haringey mental health trust's "inadequate" response to Mr Brown's cardiac arrest were laid out in the inquest, including the fact a duty doctor was not alerted to the emergency and proper resuscitation measures were not carried out.

The Trust’s training records showed none of the staff on duty at the time of Mr Brown’s death had a mandatory Immediate Life Support Training qualification and only two members of staff on the shift had basic life support training.

Senior coroner Andrew Walker has given the hospital until November 1 to outline how it will prevent future deaths following the incident.

Elizabeth Brown, Mr Brown’s mother spoke on behalf of all their family of how appalled they were at the “failures in Ben's treatment and care on Avon Ward”. 

She said: “Even though my son had previous hospital admissions, he had been well for seven years and so his death came as a dreadful shock. 

“The inquest process has been very hard as it doesn’t treat your loved one as a person and I don’t want my son to be another faceless statistic. 

“I will remember Ben as a gentle, caring and intelligent man who easily made friends. He was a talented musician who loved jazz, playing in big bands and supporting Arsenal. 

“He was also courageous and passionate about de-stigmatising mental illness and I will always be proud of him. 

“I won’t rest until I get answers from the trust about aspects of Ben’s care not dealt with at the inquest or in the hospital investigation, such as the delay in getting him admitted to hospital in the first place.”

Mr Brown had previously been a volunteer at the hospital, having played saxophone on the wards and volunteered in the coffee shop, yet when he turned to the hospital in a crisis, his mother felt he was “let down”.

Clair Hilder, a solicitor at Hodge Jones & Allen, which represented Mrs Brown at the inquest, said: “This is a very sad case of health professionals failing to consider the needs of a mentally-ill patient and then trying to cover-up their mistakes. 

“This case highlights a disturbing trend that I have seen in a number of cases where observations which are supposed to be made to safeguard patients are not taking place.”

In a statement, Barnet, Enfield and Haringey Mental Health Trust said: "The trust would like to offer our sincere condolences to the family and friends of Benjamin Brown.

"The trust is committed to providing safe patient care and as part of that process the service had already commenced making changes to their procedures following an internal investigation of this incident.  We will be providing the coroner with further information as to the progress of changes in a formal response."