A PATIENT whose health made him a "walking time bomb" died alone on a mental health ward - and notes were missing from records in his final hours.

At the time of his death, Joel Eneke, 32, had been placed "in seclusion" at Mill View Hospital in Hove and was supposed to be under constant watch.

An inquest heard that every 15 minutes, staff were meant to make notes on Mr Eneke - who had treatment-resistant schizophrenia - but a whole hour's worth were not there.

Mill View apologised to his family after a coroner highlighted "points of learning" including "the need to maintain accurate records".

Senior coroner Veronica Hamilton-Deeley said: "At the heart of seclusion is the monitoring that needs to take place, and the seclusion is only as good as the monitoring.

"I find it quite surprising that a whole hour of observations from 1am until 2am are not noted. I'm not sure I've ever seen a whole hour completely missing.

"Patients in seclusion are very vulnerable and I do believe more emphasis should be placed on selecting members of staff carefully."

Mr Eneke had been placed in a seclusion room two days previously for safety reasons after two incidents involving other patients.

He was not breathing when staff came to conduct a seclusion review at Mill View Hospital in Hove on the morning of Saturday, December 28, 2019.

Mr Eneke was confirmed dead by paramedics just after 6am.

The coroner said Mr Eneke's care at the hospital had been "excellent" - apart from missing notes - and that he died of natural causes.

She went on to add that the layout of the seclusion unit could be improved to help staff observe patients more easily.

The coroner said: "It's a big ask to expect someone to stand for the best part of an hour at a time looking through a window.

"It seems to me that the geography needs reviewing and possibly remodelling."

Up until shortly before his death, Mr Eneke had been living independently in accommodation provided by Route One, a specialist service run by Brighton Housing Trust, in Carlisle Road in Hove.

He was reported to have been enjoying his independence and living in his own flat, after years spent in institutions.

The inquest heard he had recently stopped taking his clozapine medication and had a sudden psychotic relapse. He was detained on Saturday, December 21.

The coroner described his medication as "life-saving" and said she was "not entirely sure" why he stopped taking it.

She added: "I believe he must have had a reason in his own mind for stopping it. I'm satisfied this is why he had a relapse."

Mr Eneke had been at Mill View for just one week when he died.

The coroner concluded Mr Eneke died due to acute bleeding from a catastrophic haemorrhage caused by gastritis, with a background of sleep apnoea, a very high body mass index and schizophrenia.

She said: "I believe what happened to Joel in the early hours could have happened to him at any stage of his life. One doctor described him as a ‘walking time bomb’.

"I'm convinced everything that happened to him happened in the last hour."

A spokesman for the Sussex Partnership NHS Foundation Trust said: "We would like to offer our sincere condolences to Joel Eneke's family.

“We are committed to providing safe, effective, high quality care.

"While the coroner noted the excellent care provided to Joel, there were points of learning highlighted that included the need to maintain accurate records.

"We take the findings extremely seriously and will use them as part of our ongoing work to continue improving our services and the care we provide.”

Joel's mum, Carel Eneke, described him as "gentle, kind, thoughtful and generous".

She said: "He enjoyed helping other people and would often bring little gifts to the house for his grandmother. Joel absolutely adored his nieces and nephews and delighted in playing with them. 

"He had a passion for cooking, especially for others and music was undoubtedly a part of his soul.

"Being hospitalised for such lengthy periods caused additional struggles adapting to society and he often felt lonely and disillusioned. 

"Joel was endearing, humorous and a loveable character, who despite his difficulties he still had hopes and dreams like the rest of us. 

"Our family will never be the same without him and we all miss him dearly."