Inquest into the death of Mr David Clark

Preston Coroners Court – 3^rd – 6^th February

Before HM Assistant Coroner Mr Cronin

Mr Clark was subject to a Section 3 Mental Health Act detention order. He had been receiving care for number of months at the The Orchard in Lancaster, under the management of Lancashire Care NHS Foundation Trust.

On the 26^th June 2019 during a shift change at 19.25 Mr Clark exercised his Section 17 leave privileges and left the unit to go for a walk. According to the Safety and Security form he was due to return by 20.25 and had gone for a walk in the grounds. Evidence was heard Mr Clark had told staff he was going for a walk by the canal, as he often did.

At 22.39 when he failed to return, the unit contacted the police. Various checks and searches of known locations had been made. A search of Mr Clark’s room found a diary, and an entry on the 8^th June a concerning entry was made. However, this specific entry was not discovered by staff until 11.00 the following morning, after Mr Clark’s body had been found.

The police located Mr Clark’s body in the canal at 09.10 on the 27^th June 2019.

The Jury concluded in a lengthy narrative that the leave form had been inadequately filled in upon leaving the unit and that staff were aware he was missing at 20.30.

The Jury went on to state that there was a “lack of rigorous adherence to the Trust AWOL policies and procedures in respect of S17 leave which may have contributed to the events that followed”.

David was found to have taken his own life and the cause of death noted as 1a Drowning.

HM Assistant Coroner Mr Cronin concluded a Regulation 28 letter was appropriate in this case listing the matters of concern as:

(1) That documentation in relation to leave was not completed fully and incorrect forms used

(2) That AWOL procedure was not followed

(3) That the handover was not undertaken between Safety and Security workers

(4) That there was a lack of training on policy and procedure.

(5) That there remains outstanding an appropriately sufficient action plan.

David’s family were assisted by Mr Simon Murray of St. John’s Buildings Chambers and Farleys Solicitors specialist inquest team who secured exceptional case funding on their behalf for them to be represented throughout the inquest proceedings.