A coroner is to call on Northwick Park Hospital to ensure all patients are medically assessed unless they pose a physical danger.

The move follows the death of Liam Gatrell, 29, of Eastcote Lane, South Harrow, a drug addict found dead outside the hospital after being ejected from its casualty department.

An inquest was opened at Hornsey Coroner's Court in January but adjourned to last week to allow a key witness to be traced. The resumed hearing heard Mr Gatrell's body was found beside Watford Road, Harrow, on October 7. He had twice been ejected from the hospital the previous night for allegedly violent and abusive behaviour.

After the first time, he was arrested at a minicab office on suspicion of being drunk and disorderly and taken to Harrow police station. A police doctor who believed he had taken an overdose recommended he be taken to hospital. But he was ejected again. A post mortem revealed Mr Gatrell had taken mylobarbitone at near fatal levels and diazepam, which would have made him seem drunk.

Pathologist Dr Rufus Crompton believed Mr Gatrell, a builder with an eight-year-old daughter, fell and inhaled vomit. He gave the cause of death as multiple drug poisoning and inhalation of vomit. But he was unable to say when the drugs had been taken.

Mr Gatrell had been in Hillingdon Hospital after taking an overdose two days before his death and had been referred to NPH by his GP the day after his release. He had spent most of the afternoon and evening there but was released because doctors could find nothing wrong.

Registrar Dr Shirley Rigby referred him for psychiatric assessment to Dr Nwubwa who was unable to carry out a full review because Mr Gatrell was drowsy. But he said: "There was no psychological reason to keep him in. I didn't think he was suicidal. Some of his comments referred to hope for the future."

Mr Gatrell was "not in a reasonable condition to send home". but had refused a psychiatric bed, although the doctor had been under the impression he would be kept in overnight.

Dr Rigby said emergencies were "pouring in" and she decided to discharge him. Mr Gatrell became aggressive and security staff were called. But he ran off.

Security staff and police were called during his second visit, at about 2am, because he became abusive. He was escorted from the hospital and a police officer found him at a bus stop at 2.15am when he said he could make his own way home. His body was found at 6am.

Recording a verdict of misadventure, Coroner Dr William Dolman said: "Mr Gatrell has been abusing drugs and alcohol for many years. He was clearly a very difficult patient at times. There was a huge amount of medical input over the last few days. The family doctor had the patience of a saint to keep someone like him on his list."

There was no evidence to support the suggestion that "neglect" should form part of the verdict unless it led directly to his death, although the case might indicate "less than perfect treatment".

"I will be making a recommendation to Northwick Park Hospital authorities along the lines that patients should not be removed from the accident and emergency department unless they have been assessed by medical staff, or unless to do so would be unreasonable, including the question of consent and danger to personnel," the coroner said.

"There is no doubt Liam Gatrell could be almost like a saint, and at other times be very difficult, not only to staff but others around him. Staff had every right to fear for their safety."

Last week we incorrectly referred to Mr Gatrell as a "drug dealer" instead of an addict. We apologise for any distress caused to his family and friends.

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