What happened
On 17 June 2003 Mamade “Eshan” Chattun, 43, a healthcare assistant, was working on the John Meyer ward at Springfield Hospital in Tooting, south London. He was supervising Joseph Cann, 22, a newly sectioned patient who had threatened his social worker, refused medication and attacked other staff.
Cann was held in a locked hospital lobby, with Chattun watching him from a nearby office. Cann attacked him there and Chattun died of his injuries.
Chattun carried no walkie-talkie and no personal alarm, and the fixed alarm on the wall nearby was broken. He had been told not to deal with Cann alone, and he was the only nurse left with him.
The outcome
Cann was convicted of manslaughter and detained indefinitely at Broadmoor.
In May 2005, at the Old Bailey, South West London and St George’s Mental Health NHS Trust pleaded guilty to breaching section 2 of the Health and Safety at Work Act 1974. It was fined £28,000. The HSE called it one of the most serious breaches in the NHS’s history. The trust was the first NHS body indicted at Crown Court level under the Act.
Judge Gerald Gordon criticised the holding area, and Chattun being left alone with too few checks from other floors. No prevention of future deaths report is recorded.
What went wrong
The trust had not required staff to carry personal alarms even when fixed alarms were broken, and its risk assessments were unsatisfactory. The central risk, the HSE said, was holding an aggressive patient in that lobby at all, when procedures should have been clear, safe and up to date.
After the case the trust installed CCTV, a new alarm system, more qualified staff and a unit for challenging behaviour, at a cost of £750,000, according to the Guardian.
The control that failed only matters on the day it is needed. A wall alarm can be broken for a week without changing a shift, unless someone tests it, records the test and decides what staff carry instead. Nobody had.
What it teaches
A worker in a building full of people is still alone if nobody can hear them. Chattun was on a ward, with colleagues on other floors. None of that reached him in the time it took.
The instruction not to deal with the patient alone is the other half. A two-person rule is only real when the second person is in the room. When they are not, the answer cannot be that the worker carries on and hopes. It has to be that the task stops.
The alarm chain has an owner too. Somebody tests the fixed alarm, records the result and supplies personal alarms when the fixed system is down. Here, nobody had done it.
Questions for the room
- Which alarm did you carry on your last shift, and when was it last tested?
- Your wall alarm has been broken since Monday. What does your manager say you carry instead?
- You are told not to deal with a patient alone. What do you do when you are the only one there?
- Who signs off that the alarms on your ward work, and where is that written down?
Evidence and limits
Confidence: confirmed. Three independent sources were read in full, the Guardian, BBC News and Community Care, each reporting the case in May 2005, and they agree on the sequence, the plea and the fine. This page does not describe the assault or the injuries. The sources do not record how the ward was staffed that day, or how long before Chattun was found, so neither is stated.
Our lone working training covers the alarm and check-in chain for staff who work out of sight of colleagues.
Sources
- The Guardian, May 2005 · https://www.theguardian.com/society/2005/may/05/hospitals.mentalhealth
- BBC News, May 2005 · http://news.bbc.co.uk/2/hi/uk_news/england/london/4517205.stm
- Community Care, 2005 · https://www.communitycare.co.uk/content/news/london-trust-faces-fine-for-failure-to-prevent-manslaughter-of-nurse
Reviewed 20 October 2026.