Published 13th March 2025

Jury finds staff observations in a psychiatric intensive care unit were insufficient and contributed to the death of Henok Gebrsslasie, a 23-year old asylum seeker.

Henok Gebrsslasie was an asylum seeker from Eritrea. He died on 12 August 2021 after applying a ligature whilst detained on a psychiatric intensive care unit. A few minutes before he died he was seen by a student nurse. He was sitting on the floor with the ligature around his neck expressing that he “wanted to sleep forever”.  Henok should have been observed every 15 minutes but he was not discovered for 3 hours, despite records being wrongly created by staff recording that he had been seen.

An inquest jury has now found that the observation carried out by the student nurse, which lasted around 30 seconds and after which the student nurse left the room, was insufficient and contributed to his death. The jury also found supervision on the ward was lacking which led to policies and procedures not being followed, leading to Henok’s death.

Charlotte Haworth Hird and Emily Hobhouse of Bhatt Murphy solicitors act for Henok’s family, instructing Laura Profumo of Doughty Street Chambers.

The family’s full statement following the inquest can be found here.

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