Inquest Concludes Failures in Medical Care After Suicide Attempts Were “Dismissed”

The inquest into the death of Daniel Lee Kirton (Danny) concluded this afternoon (13 January 2022).

Heard over seven days at Manchester City Coroner’s Court in front of HM Area Coroner Mr Zak Golombeck; the inquest heard evidence from Danny’s brother and he was described as a kind and compassionate man who had struggled with his mental health for a long time.

The Coroner concluded that Danny died of chest injuries, after being struck by a car minutes after being assessed by mental health clinicians at Manchester Royal Infirmary (MRI), and that Danny’s death was as a result of suicide.

Danny sadly died in the early hours of 4 December 2020 at MRI. On 3 December 2020, he attended the Emergency Department at MRI, complaining of a recent assault and also requesting a mental health assessment, referring to losing his accommodation and expressing suicidal feelings with an active plan. He was treated medically and handed to the Mental Health Liaison Team at around 10:15pm.

A joint assessment with two mental health practitioners took place where Danny said he needed to be admitted to hospital for detox from Spice and to address his recent homelessness. On assessment, the mental health practitioner taking the lead found no signs of depression or psychosis. At the inquest, the practitioner accepted that she did not document, though she recalled, exploring Danny’s suicidality.

The practitioner explained Danny became threatening when she was discussing community options and made a threatening gesture to cut his neck. Security members attended and Danny was told of their discharge plan. Danny was then escorted from the building by security officers. The officers were given no instruction by the mental health practitioners upon Danny leaving the Emergency Department, something that the Head of Security told the inquest she would have expected.

One of the security officers described the behaviour as “verbally aggressive not physically aggressive”. The officers gave evidence that Danny told them on numerous occasions that he wanted to die and was going to kill himself. Whilst on the hospital grounds outside, Danny attempted to hang himself from a tree using a piece of clothing as a ligature.

The officers then sought assistance from the Mental Health Liaison Team and the two mental health practitioners who previously assessed Danny went to see him outside. The practitioner that took the lead said that he did not think there was any intention for Danny to end his life. Danny continued to make threats including “I’m going to kill myself” and “I want to die now”.

After approximately four minutes outside with Danny, the practitioner felt they were at an impasse and their presence was making Danny more upset. He explained at the inquest that he felt the risk was the same when Danny was assessed in the Emergency Department, medium to low risk, and that Danny was “pushing” for an admission. The security officers gave evidence that they did not feel supported by the mental health practitioners and that the practitioners were not taking Danny seriously and were dismissive.

The author of the Trust’s internal investigation gave evidence that for an admission to hospital, Danny would have needed to book in again at the Emergency Department and could not have been referred directly to the gatekeepers. She gave evidence that the assessment of Danny in the Emergency Department was appropriate and reasonable however the interactions between Danny and the mental health practitioners outside the hospital building were not appropriate and Danny required further assessment.

Following the mental health practitioners’ return to the Emergency Department at 11:27pm, three security officers remained with Danny until he walked off the hospital site at 11:35pm. During this period, there were further incidents whereby he attempted to harm himself.

Danny walked off the hospital site at 11:35pm and at 11:37pm, 10 minutes after the mental health practitioners returned inside the hospital, he laid down on a road and was struck by a private hire vehicle. He was admitted to the resuscitation area of the Emergency Department at MRI at 11:45 and sadly died at 12:57am on 4 December 2020.

The Coroner found that it was an incredibly challenging assessment in the Emergency Department and that the challenges posed impacted on the practitioners’ personal views towards Danny, thus impacting on their interactions with him outside of the hospital building. The Coroner found that their input into Danny’s care when asked to go outside to see him was affected in a negative sense by their experiences during the assessment.

The Coroner found that the security officers went above and beyond in their duties and remained with him.

The Coroner found failures in the care afforded to Danny outside of the hospital building, though said these were not gross failures. The failures included both practitioners not seeking a full debrief from the security officers, particularly as at the time they arrived Danny was stood on a raised flowerbed next to a tree with a piece of clothing that, in the Coroner’s judgement, it should have been evident had been formed to be used as a ligature. This should have led to a formal risk assessment, preferably in the Emergency Department.

The Coroner said that the mental health practitioners’ minds were clouded by Danny’s previous behaviour and therefore they did not take the appropriate action. It should have been evident that Danny was presenting differently to how he presented in the Emergency Department and a further assessment was required. The Coroner, however, found that it would be conjecture to find that Danny probably would have agreed to return to the Emergency Department for a further assessment.

Kelly Darlington and Alice Wood of Farleys’ Inquests Team said:

This is a very upsetting case and the family hope that the Trust will learn from Danny’s death and will take threats of suicide more seriously. We are glad that the Coroner has identified these failings in his findings of fact and conclusion and hope that it results in change going forward.

Sam Harmel, Counsel for the Family said: “Danny was highly vulnerable and extremely desperate.  He was at high risk of self-harm and his mental state had deteriorated to such an extent that he needed to be re-reviewed in A & E.  Very sadly this did not occur on the evening of his death.  His threats were not taken seriously by the mental health nurses and they ought to have been”.