Coroner rules Warrington dad of two’s death contributed to by mental health trust failures
An inquest has concluded that the death of a devoted dad of two was contributed to by mistakes made by a mental health trust.
Recording a narrative conclusion, coroner Charlotte Keighley said on the final day of 31-year-old Adam Smith’s inquest on Friday 19th April 2024, that a plan to discharge him by Mersey Care NHS Foundation Trust was “not safe in practice”. She found that the outcome of the Mental Health Act assessment undertaken before his discharge, would likely have been different, had it not been based on inaccurate information, and had the clinicians been aware of Adam’s history. Coroner Keighley confirmed that these mistakes contributed to Adam, of Great Sankey, Warrington, being found dead on 12th February 2022.
Whilst experiencing a period of paranoia, Adam had climbed into a storm drain that went below ground at the Fiddlers Ferry Power Station and drowned. It is believed Adam first lost consciousness due to a lack of oxygen in the drain and went under the water.
Adam was suffering a mental health crisis, and was displaying signs of psychosis, when he was discharged on 27th January 2022 by a mental health team managed by Mersey Care NHS Foundation Trust, at the Royal Liverpool Hospital, at 3am in his bare feet. An appointment with his community mental health team, that was scheduled to take place at the home he shared with his mother Joanne Shillcock, and step-father Colin Shillcock at 2pm that day, was also cancelled without warning by Mersey Care staff.
Colin and Joanne contacted Mersey Care and described the deterioration in Adam’s mental health and his paranoia, and desperately tried to get the appointment reinstated. However, they were told the best they could offer was an appointment the following day. By the time they got off the phone Adam had disappeared, and his family never saw him alive again.
Adam was missing for 17 days until he was found and there was an intensive search because of his vulnerability.
Joanne said: “Adam was much loved by all the family, he was a devoted father of two young girls, and we remain devastated by his death. Not a day goes by when we don’t think of Adam, and all we have ever wanted is to find justice and answers for him and his daughters, who now have to grow up without a father.
“We welcome the coroner’s conclusion, which we believe is the right one. We fully believe that Adam would have gotten better with the right mental health support, but this was sorely lacking.”
Rebecca Cahill, a medical negligence solicitor at JMW who is handling the family’s legal case against Mersey Care NHS Foundation Trust, said: “The inquest has been a harrowing process for Adam’s family, and they have had to hear distressing evidence about his final days and the missed opportunities to help him. I will now be working with Adam’s family to take legal action against Mersey Care, which needs to be held fully accountable for its failures, in order to prevent another death like Adam’s.”
Coroner’s verdict available on request
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