The inquest into the death of Daniel, a 37-year-old man, concluded on 12th September 2022. The final inquest was held over 6 days before HM Assistant Coroner for Lancashire and Blackburn with Darwen, Mr Nicholas Rheinberg.

Daniel sadly died in April 2020 having accidentally self-administered an overdose of heroin.

The Coroner concluded that Daniel’s death was drug related and found that the following failures on behalf of the hospital charged with his mental health care contributed to his death:

  1. As a result of inadequate attempts to obtain a full medical history for the deceased there was a failure to appreciate the full extent of the risk that the deceased posed for himself if not properly supported upon discharge from hospital.

  2. In breach of a statutory duty in this regard there was a failure to properly plan and manage the deceased’s release from section 3 detention.

At an early age Daniel became involved with drugs and the inquest evidence suggested that by the age of 18 Daniel was suffering from schizophrenia, though the distinction between drug induced psychosis and schizophrenia may have been difficult to draw.

Daniel’s lifestyle brought him into conflict with the law and he was in and out of prison for a number of years. There were concerns over Daniel’s mental health and upon release from prison in November 2019, a bed had been found for Daniel at the Meadowbrook Unit, Salford. Daniel was clearly psychotic and a section 2 order was deemed appropriate, which was replaced by a section 3 treatment order in December 2019.

There was an acknowledgement that Daniel would need extensive discharge planning from the ward in order for him to return to the community, once his mental state had improved. The Coroner found that such planning as took place was fragmentary, poorly coordinated and unsatisfactory and also that generally throughout Daniel’s stay on the Meadowbrook Unit the standard of note taking was poor. There were times that Daniel was able to access drugs and was found on the unit appearing to be intoxicated.

The inquest had the benefit of an independent expert in psychiatry, who revealed a catalogue of failings in relation to Daniel’s treatment and care during the time that he was detailed at the Unit.

The Coroner found that there was a failure to obtain a full medical history and as a result the extent of Daniel’s problems was underestimated. The Coroner found that without proper discharge planning and coordination, it was very likely that Daniel would suffer a relapse so far as his mental condition was concerned and return to his dangerous drug taking practices. The discharge plan led to Daniel being located in hostel type accommodation alongside other habitual drug users. The Coroner found it would have been unrealistically optimistic to believe that Daniel would not inevitably be drawn back into a drug culture.

Article 2 and Legal Aid Funding

In certain circumstances, bereaved families are eligible for legal aid funding for representation at the inquests into the deaths of their loved ones. If the Coroner rules that Article 2 of the European Convention of Human Rights is engaged, it is more likely that legal aid will be available for families.

At a Pre-Inquest Review Hearing in 2021, the Coroner requested submissions on whether Article 2 was engaged. On behalf of Daniel’s family, we submitted that Article 2 was arguably engaged. The Trust submitted that Article 2 was not engaged.

The Coroner made an interim ruling that there was insufficient information definitively to determine whether Article 2 was engaged and that the matter would be kept under review. Following receipt of the expert evidence, the Coroner made a further ruling and was of the view that further evidence may reveal systemic failures in relation to the care provided by Daniel and so the issue as to whether or not Article 2 is engaged would remain open.

Farleys reported the Coroner’s rulings to the Legal Aid Agency and made submissions as to why funding should continue to be granted to Daniel’s family. Following our submissions, the Legal Aid Agency confirmed that legal aid funding would be in place for the inquest proceedings.

At the conclusion of the inquest evidence, the Coroner found that Article 2 was engaged and that the Trust responsible for the hospital’s practices and procedures had failed to put in place adequate systems ensuring that the discharge of a patient from a section 3 order, and in particular a discharge to an area outside of the operating area of the Trust, complied with the requirements of the Mental Health Act.

The family were represented by Kelly Darlington and the inquests team at Farleys Solicitors and Rebecca Sutton from St John’s Buildings Barristers Chambers.