The inquest into the death of Daniel Ball concluded on 14 November 2025, with the jury finding that Daniel died due to a severe hypoxic brain injury as a result of hanging.
Whilst the Jury determined that Danny, as he was known to his family, had deliberately self-ligatured, they could not be satisfied that he intended to take his own life.
The Jury found there were contributing factors which led to Danny’s actions which ultimately resulted in his tragic death.
The Inquest was heard over 4 days at Westfield House, Lewes, East Sussex in front of HM Acting Senior Coroner for East Sussex, Ms Fiona King.
Background
Danny had been known to mental health services since 2016. He was first detained under the Mental Health Act in May 2020 where he was diagnosed with drug induced psychosis.
On 29 May 2022, Danny was seen by a Sussex Liaison and Diversion Service practitioner in Hastings Police Custody. Danny was in crisis, was noted to be highly delusional and a risk to others, as well as a risk to himself having told the practitioner ‘I might as well kill myself’.
On 31 May 2022, Danny was admitted to the Pavilion Ward at Millview Hospital under S2 of the Mental Health Act.
By 09 June 2022, Danny was having escorted leave with staff, and his risks were assessed as low, but his thinking was still delusional, and he was referred for another Mental Health Act Assessment.
On 20 June 2022, Danny was further detained on a Section 3 of the Mental Health Act. The Consultant Psychiatrist described Danny as irritable, distressed, paranoid and delusional.
On 27 June 2022, Danny went on Section 17 Home Leave to his father’s house. Section 17 home leave is authorised time away from a mental health hospital for patients detained under the Mental Health Act, allowing gradual reintegration into the community.  This is considered and granted by a multi-disciplinary team and risk assessments are undertaken before the same is granted.
This went well and on 29 June 2022, Danny was granted extended Section 17 Leave to his father’s address.
Danny only returned to the ward intermittently for reviews by the Consultant Psychiatrist but was on extended home leave throughout July with his risks assessed as low.
Whilst on Section 17 leave on 04 August 2022, Danny took an overdose of his prescribed medication.  Danny’s father contacted the ward for advice and reported concerns about a deterioration in his mental health and him saying ‘I don’t want to be here anymore’
Despite the overdose, attendance at A&E, and concerns being shared with staff, Danny’s risk to self was not seen as escalating by nursing staff and remained graded as low.
Danny’s S17 home leave was however revoked, and he was returned to Millview on 05 August 2022.  He was placed on intermittent observations (4 x hourly at irregular intervals) for 11 hours and during this time he slept.
Danny was then changed to hourly observations and his S17 leave was reinstated.
The records considered during the inquest noted that Danny remained a risk of harm by misadventure following recent overdose in the community whilst on extended S17 leave.
He was noted to appear to have been crying on one occasion but said he was okay and had not presented with any suicidality.  His mood was described as flat and low.
Danny’s father visited the ward with some of his son’s possessions and advised the Charge Nurse that Danny’s anxious/depressed presentation was because of a criminal charge that Danny was facing.
On 06 August 2022, records note that Danny was struggling with the ward environment especially with a forensic patient who was sharing their criminal history.
The following day, Danny left the ward with his father, when he should have had escorting staff with him. He was called back to the ward by staff when they realised he should not have left.
On 08 August 2022, there was a Section 117 discharge planning meeting.  Danny wanted to go home.  He felt the environment was unhelpful to him.
The Consultant Psychiatrist documented reservations about his potential discharge – acknowledging the recent overdose and him being a risk to self and others.
It was the view that Danny would be best placed at home with his father.  It was agreed that he could have two consecutive overnight leaves on the 08 & 09 August 2022.
On the morning of 08 August, Danny’s presentation was volatile.  There was a note about Danny’s inability to manage his frustration and his actions on the ward.
Danny was allowed home on leave with his father at 15:00 hours with his risks to himself and others overall being assessed as ‘low’.
On 10 August 2022, Danny failed to return to Millview.  Staff were unable to contact him, so the Consultant Psychiatrist granted a further period of overnight leave without having spoken to him or his father.
Staff eventually made contact with Danny’s family during the evening of 10 August when they advised Millview that Danny had been found suspended in his father’s back garden at 7.21am that morning.
Danny died the following day.
In an ideal world, it was accepted that Danny would have been placed in a lower secure ward, closer to home, as the PICU environment at Millview was not beneficial to him.
This was not an option due to bed availability. This is why he was allowed the extended S17 leave. The consultant was not aware of the recent interactions between Danny and the police, as well as family concerns, when the decision was made for Section 17 leave on the 8th.
Indeed, in her evidence, the consultant accepted only being made aware of the police investigation when writing her report for the inquest.
The Jury heard evidence of changes that had been made at Millview since Danny’s death.
The Jurys Findings
The Jury delivered their conclusions to the coroner on 14 November 2025.
The returned a narrative conclusion, recording:
Daniel Ball deliberately chose to suspend himself but the evidence does not fully explain whether or not he intended that the outcome be fatal. We conclude there were contributing factors leading to the incident on the 10th. The consultant was not aware of recent interactions between Daniel and the police, as well as family concerns, when the decision was made for Section 17 leave on the 8th. The risk assessments did not contain all previous accumulated information. The most significant factor leading to the incident on the 10th was the lack of suitable available beds on the open ward, which led to the Section 17 leave on the 8th.
HM Acting Senior Coroner Fiona King addressed Danny’s family at the conclusion of the hearing to acknowledge the fact that Danny had been an organ donor and his sad death had ultimately helped someone else.
Danny’s family were comforted somewhat by hearing the changes that had been made at Millview.
Danny’s family were represented by Natalie Tolley, Associate, of Farleys Solicitors and Myles Grandison, Barrister, of Temple Garden Chambers.
(Myles’ Profile – Myles Grandison – Barrister – Temple Garden Chambers)
