The inquest into the death of Sergio Dunkley concluded on Friday 6th May 2022 at Bootle Town Hall, before HM Assistant Coroner Johanna Thompson. The Coroner concluded that Sergio died as a result of suicide.

Sergio died on 18th August 2020 whilst a voluntary inpatient on Pine Ward at Hartley Hospital. Sergio ligatured from his bedroom door. The inquest heard how none of the rooms on Pine Ward contained door alarms to sound if a substantial weight was applied, namely to raise awareness of any ligature attempts by patients. The ward only opened in March 2020, as a brand new, purpose built acute mental health unit.

During the pandemic, the ward became an admission ward for Mersey Care NHS Foundation Trust as a result of the ensuite facilities on the ward. This meant that around 18 patients were being admitted per week on the ward, as opposed to the usual 4-5 patients. His family therefore had extremely limited contact with him during his admission and felt they were not adequately informed or involved in his treatment.

Sergio’s mental health rapidly declined in 2020, following a decision to not take a new job role at work, the breakdown of his relationship and two deaths in the family within a very short period of time. He made a number of threats to end his life whilst living at home, culminating in a voluntary admission to Pine Ward.

Sergio was placed under regular observations on arrival, initially requiring him to be checked every 15 minutes. The following day however, the observation frequency was reduced to one check per hour.

Mersey Care NHS Foundation Trust admitted during the course of the inquest that the rationale for the change on observations was not recorded and that the formal written risk assessment document for Sergio was not updated after 4th August 2020.

The Coroner found that the hospital staff at Pine Ward did not adequately record the rationale for the assessment of risk of suicide between 4th – 17th August 2020. She also found that on 17th August 2020, Sergio presented as significantly anxious when plans for his discharge from the ward were being discussed. She found that there was a failure by ward staff to complete a formal assessment as to whether he was at increased risk of suicide on that day. The Coroner went on however to state that these failings were not causative of Sergio’s death.

Evidence was heard from Mersey Care NHS Foundation Trust, explaining how the Trust have since gone on to install door sensors on Pine Ward and another mental health ward at Hartley Hospital, as well as in all rooms at Clock View, another mental health facility following Sergio’s death.

The Coroner however was concerned to hear that there is currently no guidance available regarding door alarm sensors in relation to new build mental health facilities. She therefore went on to issue a Prevention of Future Deaths Report to both the CQC and NHS England, regarding the use of door alarms in new build premises for mental health facilities.

Sergio’s family was represented throughout the inquest process by Kelly Darlington and the inquest team at Farleys and Rebecca Sutton, of St Johns Buildings.