In early 2019 Jayne O’Sullivan was informed of the most crushing news that any parent can learn. Her son, Dan, had died. Unfortunately, this was only the start of what Jayne describes as an overwhelming journey to find out the specific circumstances surrounding Dan’s tragically premature death and how he died under the care of mental health services who she thought would try to keep him safe.

The crude facts about his death were readily available. At about 05:46 am, on 27 March 2019, Dan was discovered having taken his own life. His body was recovered by the police, and he was pronounced dead at the scene by a paramedic.

However, the events leading to his death, were less clear.

Dan had for many years suffered from paranoid delusions for which he had sought help from mental health services. In 2018 Dan’s health deteriorated and he made a number of attempts to take his own life, leading to him being sectioned under the Mental Health Act as it was assessed that he was a risk to himself. Dan recognised that he needed help to be kept safe. He was admitted to hospital and from there transferred to a psychiatric unit run by Central and North West London NHS Foundation Trust for inpatient care and treatment. Yet, somehow in March 2019 he was able to take his own life and Jayne wanted to understand what had happened.

Unfortunately, despite Jayne’s best efforts, she could not get definitive answers, and when she was presented with a huge bundle of legal documents in advance of the inquest into Dan’s death and, she realised she needed legal advice, Eventually, Jayne got into contact with Nicola Wainwright, our Head of Clinical Negligence in London.

Nicola explains why legal help is essential in situations such as these: “the inquest process is bewildering for bereaved families. There are a lot of rules to navigate. It can be overwhelming. In a case like Dan’s where substandard care contributed to his death, we always advise families to obtain legal help if they can. The other party – here the hospital Trust – will have access to legal advice and assistance – probably an in-house legal team, solicitors, and a barrister. It is only fair and right that a family has the same access to support and legal expertise.”

With Nicola’s help, Jayne discovered the heartbreaking news that Dan’s death was almost certainly preventable. She learnt that on 19 March 2019 Dan was transferred to St. Charles Hospital still sectioned under s.2 MHA for his own safety. During his hospital admission assessment, Dan disclosed that he planned to try to take his own life again. He described the method and specified when “next Tuesday” (26 March 2019).

The day before Dan died, a consultant psychiatrist at St. Charles Hospital decided to rescind Dan’s s.2 MHA detention, without, it seems, assessing his risk of suicide and without exploring the effect on Dan of his delusional and paranoid beliefs He remained as a voluntary inpatient but received no treatment or therapeutic input and was permitted unescorted leave from the ward.

On Tuesday 26th March Dan requested the return of his bank card and passport from a member of the nursing staff and said he was going out. Despite having previously said he intended to take his own life on this day no discussion was had with him about his plans or further risk assessment undertaken. Instead, he was just given his property and allowed to leave the ward at approximately 16:20 ‘to buy cigarettes’. Despite the nature of his illness and the risk he posed to himself it wasn’t until after midnight that Dan was reported to the police as missing by a member of hospital staff.

At the inquest into Dan’s death having reviewed Dan’s psychiatric medical records and having heard evidence from hospital staff and an independent expert psychiatrist the Coroner found that there were failures in the management of Dan’s risk of self-inflicted death and in the treatment of his delusional disorder.

He described the decision to rescind Dan’s s.2 MHA detention as ‘inadequate’ highlighting the failure to carry out an up to date risk assessment and the failure to take into account Dan’s most recent expression of intent and clear plans to take his own life.

The coroner was also critical that no treatment or care plan was formulated to treat Dan using antipsychotic medication and psychological therapy.

Although Jayne welcomed the Coroner’s findings which accorded with her own concerns about Dan’s care, she felt that the hospital to which Dan had been admitted in March 2019 had not taken any responsibility for the failings identified and did not feel reassured that lessons had been learned. Jayne chose to talk to the BBC as she wanted to focus on helping to ensure that other families don’t have to go through what she has: “I sincerely hope that hospitals around the country will recognise the devastating consequences of failures in care and take on board the concerns raised by the coroner and the inquest into Dan’s death. However, if families find themselves having to attend an inquest into the death of loved one, I advise them to seek specialist legal help from a solicitor like Nicola as soon as possible. It is hard enough dealing with tragedy and loss, but trying to navigate a complicated legal structure was completely overwhelming. Seek advice as soon as you can”.