The Article 2 inquest into the death of Peter Stansfield was heard by HM Senior Coroner Terence Carney in the Coroner’s area for Gateshead and South Tyneside sitting with a jury in October 2023.


Peter Stansfield was a sociable, well-loved family man and a great father to his daughter.

Peter had suffered with mental health related issues since he was a teenager and had a diagnosis of bi-polar disorder.

In 2016 Peter attempted suicide and was hospitalised and detained under the Mental Health Act. Peter was then transferred to Elm House, a non-secure rehabilitation centre run by the Cumbria, Northumberland, Tyne and Wear Foundation Trust (CNTW).

Whilst a resident at Elm House there were numerous incidents leading to Peter becoming a danger to himself and others.

On the 7th December, Peter was to be checked by staff every 15 minutes. Unfortunately, Peter was left unattended for a number of hours and absconded from Elm House. Staff failed to realise Peter was missing and had failed to lock the door.

It was later discovered that Peter had walked in front of a metro train and sadly passed away.

Jury’s findings:

The jury’s findings in relation to the circumstances of Peter’s death can be summarised as follows:

On 7th December 2016, William Peter Stansfield died following a collision with a Metro train in Gateshead on 7th December 2016.

The jury indicated that whilst recognising the difficulties faced by medical professionals when tending to the care and treatment of complicated individuals such as Peter, the facts presented indicated that there were a number of significant areas of missed opportunities to maintain Peter’s care and safety, whilst detained under Section 3 of the Mental Health Act. These were identified as follows:

  1. A lack of completion of a formal assessment undertaken surrounding Peter’s transfer from an acute unit to a rehabilitation unit.

  2. An absence of documentation recording notes taken from multi-disciplinary meetings regarding Peter in addition to the completion of mandatory updates to Peter’s FACE risk assessment and medication templated in accordance with care policies in place at the time of Peter’s detention.

  3. A lack of intervention from relevant psychology specialists.

  4. Inadequacies surrounding the observation of Peter whilst detained and significant concerns surrounding Peter’s ability to access and utilise the unlocked front door.

With the above in mind the jury concluded that Peter Stansfield died as a direct result of missed opportunities to maintain his care and safety.

Rajesh Nadkarni, executive medical director and deputy chief executive at CNTW has stated that “our thoughts and sympathies are very much with the family and friends of Mr Stansfield at this difficult time.

“In 2017, we carried out a full Serious Incident Investigation to identify any issues or concerns and improve standards. As a result, lessons were learned and changes made to the way we work. At Elm House, this included introducing daily reviews of care documents and plans, and psychology specialists and reflective practice sessions becoming embedded in the team.

“In the seven years since Mr Stansfield’s sad death, the trust has also made additional improvements which have meant that much more robust processes are now in place for assessing and supporting patients at Elm House. For example, the Trust’s Observation and Engagement Policy has been updated a number of times to improve safety.

“The Trust is also further reviewing its approach to assessing risk following updates to NICE guidelines in 2022.”

Peter Stansfield’s family were represented by Kelly Darlington of Farleys Solicitors and Counsel Mr Andrew Bridgman of St John’s Buildings.

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