This week is Mental Health Awareness Week. Mental health is now much more widely talked about and it is often reported in the media that there is increased pressure on NHS services.

The focus on mental health is feeding into the approach at inquests and we are seeing more complex and longer inquests with increased scrutiny into the mental health services.

We are instructed on a number of inquests involving mental health care, across the country, and issues that we are repeatedly finding include:

  • The family not being involved in discussions, especially when taking an initial history.

  • Lack of communication between teams or a multi-disciplinary approach.

  • Failures with assessing risk and documenting the rationale around decision making.

  • Insufficient staffing levels on wards.

  • Records being altered post-incident.

  • Lack of consideration or documentation around capacity.

  • Failures with discharge decisions and whether the patient can be safely managed in the community.

The death of a loved one can be a devastating time. When someone has died following contact with or when a resident of a mental health facility, you are likely to have many questions around their assessments and treatment and questions of those involved in your loved one’s care.

Examples of deaths involving mental health include:

  • Where a death occurs on a mental health ward or unit due to failures in conducting observations or assessing risk level.

  • Where a patient is granted Section 17 leave without being properly risk assessed.

  • Self-inflicted deaths whilst under a mental health section.

  • Issues with treatment or medication, including where physical symptoms are associated with mental health problems, such as eating disorders.

  • Where someone in crisis has been assessed at A&E.

Some of our recent inquests include:

  • Rowan Thompson – Rowan was an inpatient at the Gardener Unit at Prestwich. The jury found that their death was contributed to by neglect due to the failure to communicate the findings of blood tests. Rowan’s inquest uncovered a number of issues, including failure to perform observations and staff falsifying observation records. You can read more about the inquest conclusions here – Inquest into the Death of Rowan Thompson Concludes Neglect

  • Daniel – Daniel died a drug related death following discharge from a mental health unit. The Coroner found that his discharge planning was unsatisfactory and poorly co-ordinated. An independent expert was commissioned by the Coroner and found a number of failings in relation to Daniel’s care and treatment whilst on the unit. You can read more about this here – Inquest Concludes Failures in Mental Health Care Contributed to Death

  • Nichola Lomax – Nichola had a long-standing history of a serious eating disorder. She was assessed a number of times at A&E and on each occasion there was a failure to recognise the severity of her condition and admit her for medical stabilisation. The Coroner found gross failures in the provision of basic care afforded to Nichola and that her death was contributed to by neglect. You can read more about the findings here – Article 2 Inquest into the Death of Nichola Jane Lomax

  • Danny Kirton – Danny died after laying down in a road minutes after being assessed in A&E. He attended requesting a mental health assessment and was expressing suicidal feelings. Following assessment by mental health practitioners, he was escorted from the building by security, then whilst on the hospital grounds he attempted to hang himself. The same practitioners attended but the Coroner found they did not take the appropriate action and a further assessment was required. You can read more about the Coroner’s findings here – Inquest Concludes Failures in Care After Suicide Attempts “Dismissed”

An ‘Article 2’ inquest will be held where the death occurs under formal health section. Article 2 can also be engaged when someone was attending on a voluntary basis and was subject to observations and risk assessments, and also in some circumstances when they were under the care of community mental health services. When Article 2 is engaged it is likely that Legal Aid funding will be available to you.

Inquests relating to mental health will often include the disclosure of lengthy medical records and witness statements from various health professionals involved. An inquest can be very daunting for the family following the loss of a loved one. Our inquests team is experienced in assisting with inquests of this kind and can guide you through the process.

We can also advise on bringing a claim for compensation after the inquest.

For more information to discuss representation, please call us on 0845 287 0939, contact us by email, or use the online chat below.