The inquest into the death of Martin Gibbons concluded on Thursday 22nd April 2021 at South Manchester Coroner’s Court.
Martin sadly took his own life on 19th March 2020. In the days prior to his death, Martin had presented with symptoms consistent with deteriorating mental health.
On the morning of 19th March, Martin attempted to take his own life. He was found by his brother-in-law and then accompanied to hospital by his sister. At Tameside General Hospital, Martin was referred to a specialist team in relation to his wounds.
The Mental Health Liaison Team from Pennine Care Foundation Trust then conducted an assessment, the consequence of which being that Martin agreed to voluntarily attend a mental health ward.
Due to Martin living outside of the area of the hospital trust, the mental health team left to try to locate a bed for Martin. Martin was left to wait in a room with his sister, with no other staff members present. Whilst this search for a bed was ongoing, Martin absconded from the hospital and later took his own life.
HM Senior Coroner Alison Mutch found that there was no evidence of any detailed discussion with Martin’s family about how the risk would be managed whilst they were waiting at the hospital. There was also no discussion about how Martin should be supported whilst waiting for a hospital bed. There was no evidence of a joint risk assessment between Pennine Care Foundation Trust and Tameside and Glossop Integration Care NHS Foundation Trust, nor was there a shared care plan to manage risks or any evidence of any individual risk assessment taking place.
The Coroner concluded that the failure to conduct a detailed risk assessment for the period the hospital bed was being searched for and the failure to agree a joint plan between the two hospital trusts probably contributed to Martin’s death.
Based on this finding, Ms Mutch requested a Preventing Future Deaths Report, involving both the Department of Health and Greater Manchester Health and Social Care Partnership, with the aim of considering a definition of high risk and the need for this definition to be shared on a national basis. The Coroner also wishes for the report to consider the availability of mental health beds and the issue of patients being assessed in one area to then be allocated a bed in another.
Martin’s family were represented throughout the proceedings by specialist inquest solicitor Kelly Darlington and her team at Farleys. Exceptional case funding was secured, due to the nature of the case.
The inquest was also reported in the Manchester Evening News.