The inquest into the death of Nicholas Sullivan concluded on 17th August 2016. The inquest was heard by HM Senior Coroner for Manchester (City) Area, Nigel Meadows. Nicholas, known by his family as “Nicky” died on 30th November 2014 having run across a carriageway in North Manchester. He was hit by an oncoming vehicle.

Nicky had for many years suffered from a chronic and enduring mental illness, namely Paranoid Schizophrenia. He was prone to rapid deterioration in his mental state. On 10th November 2016, Nicky became distressed and extremely agitated. He reported to his family hearing voices and suicidal ideation. He attended the Emergency Department at North Manchester General Hospital with his sister. Nicky was booked into reception at approximately 17:20pm and his sister informed the receptionist that he was suicidal and hearing voices. The receptionist did not document that he was feeling suicidal.

On the day in question, the Emergency Department was experiencing excessive demand for services from approximately 10:00am. The increasing numbers of patients entering the department every hour was documented by the nurse in charge. In accordance with National Guidelines and the department’s own internal policy, they failed to trigger an escalation policy at any point throughout the day which would have allowed for a secondary triage point and additional resources to be utilised to relieve the demands on the department. Triggering of the escalation policy could have been actioned by any of the staff working within the department. Evidence was heard that it ought to have been obvious to those in charge that the department was overstretched. Failure to trigger this policy was found to be a “serious and significant failure” by HM Senior Coroner.

Nicky was asked to wait and in line with long established national guidelines should have been triaged within 15 minutes. In fact, he was never triaged. Nicky was left unseen by anyone for 1 hour 20 minutes despite his sister reminding the receptionist that he was suffering from suicidal ideation and speaking to a member of the nursing staff. Nicky left the hospital and went home. Had Nicky been triaged he would have been referred for a mental health assessment by a mental health nurse. He would have been managed better within the environment he was in and measures such as a risk assessment, quiet room and support could have been put in place to support him whilst he waited to see the mental health nurse. Evidence was heard from a number of the witnesses working within the Emergency Department who could not say why the escalation policy had not been triggered or why Nicky had not been triaged. Evidence was heard from the Lead Nurse in Urgent Care that the timescale for triage had got increasingly longer throughout the day and there was a consistent failure to maintain triage times over many hours.

Sadly, in the hours that followed Nicky leaving the hospital he ran across a highway and then stopped in the middle of the road before he was hit by a car. It was not possible to determine that he had deliberately intended to take his own life and as such the Coroner could not safely come to a conclusion of suicide.

The Coroner returned a narrative conclusion having given a lengthy summing up of the evidence and highlighting the serious and significant failings by the hospital.

Despite hearing evidence from the hospital Trusts as to the changes that have been made to policies, procedures and practices since Nicky’s death, it was alarming to hear that to date these have not yet been fully implemented, nearly 2 years later. HM Senior Coroner also raised concerns over the lack of focus and delay in the Trusts own investigations into this death. HM Senior Coroner intends to issue a Prevention of Future Deaths Report to both Trusts and proposes to disclose this to other NHS Trusts within Greater Manchester, the Secretary of State for Health and the Medical Director of the NHS. The report will address communication, shared accommodation, templates, policies and procedures of both NHS Trusts at North Manchester General Hospital.

At the conclusion of the Inquest Nicky’s sister Lisa Sullivan said on behalf of the family: “We are pleased it’s been recognised there were serious failings by those who were supposed to be looking after Nicky. “What is the point in offering a service when you don’t do it right?

“The phrase ‘lessons learned’ is used too much – it has to start to mean something.”

This case is a clear example of an extremely vulnerable person in obvious need of professional help being taken to a place of safety and not being cared for as he should have been by those entrusted with his care and safety. There were missed opportunities by staff working within the department to recognise and appreciate his vulnerability and ensure that he was prioritised and received the help needed.

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