29 Sep INQUEST INTO DEATH OF BENJAMIN BROWN CONCLUDES
25 September 2025
29 September 2025
Benjamin Brown: Jury finds failings by East London NHS Foundation Trust and the Metropolitan Police possibly contributed to the death of 35-year-old musician.
Before HM Assistant Coroner Jonathan Stevens
Inner North London Coroner’s Court
15 September – 25 September 2025
CONTENT WARNING: This press release contains themes of self-harm and suicide
Ben was a talented musician and composer. He was loved and cherished by his family and by his partner, James Ferguson.
Ben began to experience mental health issues during lockdown towards the end of 2020, and his partner became increasingly concerned about the paranoid thoughts he was having. Ben became fixated on thoughts that he was a messiah being appointed to save the world. Ben went missing in December 2020 resulting in him being sectioned at Homerton Hospital under the care of the East London NHS Foundation Trust (‘ELFT’).
It was considered that Ben was suffering from psychosis with depression and he was discharged into the care of Early and Quick Intervention in Psychosis (‘EQUIP’) services in the community. Ben was assigned a care coordinator but had no face-to-face appointments for four months until April 2021. At the end of May 2021, Ben stopped taking his medication and was again admitted to hospital on 11 June having become acutely unwell. On 17 June 2021, Ben’s care coordinator decided that Ben did not need to remain in hospital despite the fact that two psychiatrists and Ben’s father and partner considered that Ben needed to be sectioned in hospital.
Just 24 hours later, Ben was re-admitted following an incident of self-harm. On 15 July 2021, Ben was again discharged into the community. On 16 July 2021, Ben had his first psychology appointment, having been on a waiting list since December 2020, something that his family had repeatedly chased with ELFT. While in the community, Ben deteriorated and took a deliberate and near fatal overdose on 25 July 2021. Ben was admitted to hospital once again and sectioned. He remained on the Ruth Seifert ward at Homerton Hospital until his death.
Whilst on the ward the jury heard that Ben had a pattern of masking his symptoms with professionals and minimising his delusions. On 4 November 2021, Ben was last seen by his Responsible Clinician (‘RC’) before she unexpectedly went on long-term leave. Ben was then not assigned a single RC but a number of clinicians covered his case.
On 25 November 2021 during a multi-disciplinary team (‘MDT’) meeting, Ben’s risk was considered and a decision made to grant Ben unescorted leave (‘UEL’) for the first time. Ben’s RC had previously refused to do this, considering that his risk was too high. Ben’s family were not consulted about this decision to grant UEL and between 25 November and 14 December 2021, Ben’s UEL was escalated rapidly from 30 minutes twice per day to 6 hours a day with no consultation with the family. The jury heard that there was an absence of monitoring Ben whilst he was utilising his UEL or his escorted leave (EL). There are no records to show Ben’s mental state was checked before he went out on leave nor was it recorded where he was going on his leave. It also appears that on some occasions, Ben was allowed to run his UEL and EL back-to-back without returning to the ward.
On 15 December 2021, Ben left the ward after morning medication, although no one could say what time that was. The jury heard how from November 2021 no section 17 leave forms have been recovered for Ben and no sign in and sign out sheets have been provided that document Ben leaving and returning to the ward.
On 15 December 2021, James returned to his flat at 6pm and found Ben there. Ben seemed very low and depressed. They had dinner together and Ben told James he was due back on the ward at 8pm. James asked Ben to send a photograph of him when he was back on the ward to prove he had arrived. Later that evening, James received the photograph, but it appeared to be one Ben had previously sent. James was immediately concerned and contacted hospital staff who advised Ben had not returned. James was told to wait 10 minutes. James then saw that Ben had posted a poem on Facebook that indicated, in his view, suicidal intent. James became even more worried about Ben’s safety and felt he had gone to harm himself. James contacted the hospital again and was told to call the police. The jury heard how this was not in accordance with ELFT’s absent without leave (‘AWOL’) policy and that hospital staff should have taken responsibility for calling the police and carrying out immediate actions following the discovery that Ben had absconded.
At 9:12pm, James contacted the Metropolitan Police and provided significant information about Ben and his serious concerns that Ben had gone to take his life. The police however, without seeking any information from the hospital as to risk, decided to grade Ben as a medium risk missing person. Between 15 and 16 December 2021, the family called multiple times to request that Ben’s risk be escalated to high, which would likely prompt a more intensive search from the police. At 3:37pm on 16 December 2021, about 19 hours after Ben had gone missing, the hospital contacted the police and gave them the information that Ben was a high-risk missing patient. The jury heard that the hospital should have done this sooner and that Ben was considered high risk once he went missing. At 5:23pm, the police increased Ben’s risk to high and carried out further actions, including obtaining Ben’s phone location data, which showed Ben’s last known location to be near James’ flat and Wick Woods. James had previously told police he suspected that Ben may have gone to the woods.
On the morning of 17 December 2021 around 8am, Ben was sadly found dead in Wick Woods by 2 dog walkers. A pathologist told the jury that Ben had died from an overdose and gave a probable window of death as between 2pm on 16 December 2021 and 2am on 17 December 2021.
After hearing evidence for two weeks, the jury concluded that Ben died as a result of drug toxicity and added the following:
“The lack of virtual (in the absence of face to face) consultation and early access to psychology treatment was inadequate.
The following have 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
In conclusion, Ben died by suicide and failures mentioned above possibly contributed to his death.”
Ben’s partner James Ferguson stated: “I draw immense comfort from the fact that the truth about Ben’s death has finally been brought to light. After so much pain, uncertainty, and denial, it is a significant step towards justice and healing. Most importantly, Ben has finally been given the dignity of having the facts of his death made clear and transparent.
“I sincerely hope that this marks the beginning of a genuine shift in culture—from one where mistakes are routinely denied, minimised, or obscured, to one where accountability, learning, and action are prioritised. It is essential that lessons from Ben’s case are not only acknowledged but are acted upon, to ensure that no other family has to endure the same tragedy.”
Ben’s father Peter Brown stated: “We have been struggling for four years to try to obtain the truth about the death of my son, but we have faced inaction and what we feel are coverups by the Trust. This has put immense stress on us all.
“The independent Niche report commissioned by the Integrated Care Board was a damning analysis of the Trust and of my son’s treatment, but was not part of the evidence. Nonetheless, the jury still identified six matters of action or inaction which possibly contributed to Ben’s death. I would like to thank the jury for their complete ability to recognise the truth.
“I was proud to play one of Ben’s songs ‘Indelible Fire’ to the Court after the inquest and to dedicate it to his loving memory”
The family’s solicitor Christina Juman, of Deighton Pierce Glynn said:
“The family have had to fight for the truth at every stage of the process, and it is a testament to their strength, determination and resilience that they have bought the issues in Ben’s case to light.”
We await confirmation as to whether the Coroner will make a PFD report in this case.
ENDS
If you are affected by the issues in this release, Samaritans are available 24/7. Call 116 123 free, email jo@samaritans.org, or visit www.samaritans.org.
Notes for the media Please refer to the Samaritans’ guidelines on reporting inquests: https://www.samaritans.org/about-samaritans/media-guidelines/guidance-reporting-inquests/
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Ben’s family were represented by INQUEST Lawyers Group members Christina Juman of Deighton Pierce Glynn solicitors and Mirren Gidda of One Pump Court Chambers.
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Other Interested Persons represented include the East London NHS Foundation Trust and the Metropolitan Police.
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Request for photographs and further information should be directed to londonadmin@dpglaw.co.uk.
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