A coroner has criticised the Whittington Hospital over its care of a young father who fled A&E before falling to his death.
A police missing persons hunt was launched after Dominic White ran away from the Archway hospital in November.
The 27-year-old, who had bipolar affective disorder and psychosis, had been well but was sectioned under the Mental Health Act when his condition rapidly deteriorated in the days before his death.
The security guard, from Crouch End, walked out of A&E on November 9 before he could be moved to a specialist mental health unit.
His body was discovered at an electricity substation the next day.
St Pancras coroner Mary Hassell has issued a prevention of future deaths report amid concerns over monitoring of A&E patients at The Whittington.
It reveals Mr White was allowed to leave the hospital to visit McDonald’s on the day he absconded. He returned only to run out again 30 minutes later and never came back.
The coroner said allowing leave after he had been sectioned was “a very unusual step”.
“I am concerned at the lack of recognition, even so long after the event, that allowing a person to leave the hospital in these circumstances was not necessarily the right [step],” she said in the report.
It also says Mr White’s return within half an hour may have “lulled others into a false sense of security about the risk of absconding” and the decision by a mental health worker to authorise leave should have been discussed with a colleague.
The coroner said observations of mental health patients at The Whittington’s A&E are now clearly documented. But she was “not sure robust protocol” is in place to ensure all hospital employees, including doctors, nurses and security officers, are aware of this.
A spokeswoman for The Whittington offered “deepest condolences” to Mr White’s family and said a full investigation was conducted following his tragic death.
She said: “We have already taken significant steps to ensure that we learn from the important lessons identified from Mr White’s death.
“The care and safety of our patients remains our first priority and we have already put into place a number of extra measures to protect vulnerable patients when they arrive.”
A jury at St Pancras Coroner’s Court identified a series of failings by mental health services over the care of Mr White following an inquest into his death in May.
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