Inquest into the death of John Paul Pratt

At Warrington Coroner’s Court

Before HM Area Coroner Victoria Davies and a jury

11-15 November 2024

On 15 November 2024, the inquest into the death of John Paul Pratt concluded, with the jury finding John died of suicide contributed to by neglect. The jury found that there had been a complete and total failure to provide basic care to John which probably contributed to his death. The jury recorded a large number of failings in John’s care. They found that failings in risk assessment and lack of action taken on 8 September possibly contributed to John’s death.  They found that failings in risk assessment, communication between teams and lack of action on 9 September probably contributed to John’s death.

John presented to the Countess of Chester Hospital Emergency Department on Friday 8 September 2023 after suffering an acute episode of psychosis. John had a history of Post Traumatic Stress Disorder following a career as a firefighter. His severe psychosis led him to take steps to take his own life, but fortunately he was able to seek help at that point.

Tragically, although he sought help, hospital failings led to his death that weekend.

John’s mental health was assessed, and it was agreed he required admission to a mental health unit. Due to the national bed crisis, there were no available beds. John and his partner waited in a small windowless room off the emergency department for two days. It was accepted at the inquest that the emergency department was not a safe environment.

1:1 support was requested but was only in place between 8:30-9:30am on Saturday 9 September. This support was removed due to a lack of staffing. The support worker raised concerns to his management and with Psychiatric Liaison Team (PLT) staff from Cheshire and Wirral Partnership NHS Foundation Trust (CWP) at the hospital, as he did not feel it was safe to leave John. No assessment of John’s risk to himself was undertaken before support was removed, and no plans were put in place to replace that support.

A further assessment was undertaken on the Saturday morning. This assessment failed to correctly identify John’s high risk to himself. It confirmed that John did require a mental health bed, however, there was none available, and he was told he needed to change GP to be put onto a CWP waiting list.

On the Saturday evening, John’s mental state became worse, and he was exhibiting severe suicidal thoughts. John’s partner sought help from an emergency department nurse. She was very concerned about how withdrawn John was and called CWP mental health staff to attend. Although they attended, they failed to conduct any assessment, they did not ask John any questions and the evidence shows that no plans were put in place to support him.

In the early hours on Sunday 10 September 2023, John’s partner had gone home to collect paperwork to change GP, alerting emergency department staff before she left of John’s high risk to himself. No checks or observations were made of John, despite there being a policy in place requiring this. John left the room unnoticed and took his own life.

The family were very disappointed about the quality of the evidence given by CWP staff. It was clear that, unlike the Countess of Chester Hospital emergency nurses, members of CWP staff had not reflected or learned lessons following on from what happened to John. The family are extremely concerned that the same failings could be made again by CWP staff.

Janine Carden, John’s partner, said:

“John was an amazing person. One of life’s helpers, a much-loved partner and father who attended A&E to seek help. He should have received the help he needed but did not, and this tragically led to his death. His death identifies serious flaws in the care of vulnerable mental health patients who are at risk of self-harm.”

Alice Wood of Farleys Solicitors said:

“No-one in John’s position should have been left in the way he was, which is demonstrated by the jury’s finding of neglect. We are grateful for the detailed consideration of the inquest evidence by the Coroner and the jury, which has highlighted that there is a lot of learning required. It was concerning to see that some of the witnesses didn’t seem to grasp the importance of the missed opportunities highlighted to them.”

John’s family were represented by Alice Wood and David Corrigan of Farleys Solicitors and Mira Hammad of Garden Court North Chambers.

The other Interested Persons were the Countess of Chester Hospital NHS Foundation Trust and Cheshire and Wirral Partnership NHS Foundation Trust.