Charles Andrew STONLEY · Prevention of Future Deaths report

On 17 March 2025 I commenced an investigation into the death of Charles Andrew STONLEY aged 50. The investigation concluded at the end of the inquest on 19 August 2025. The conclusion of the inquest was that:

Narrative Conclusion: Self ligatured whilst suffering from a psychotic episode

Charles Andrew Stonley was a 50 year old gentleman who had a medical history of severe depression with psychotic features (diagnosed in 2018) for which he was on medication. In September 2023 Charles had been detained under section 2 of the Mental Health Act.

On 12 March 2025 Charles attended Arrowe Park Hospital at 8.51pm with suicidal ideations, he was tearful, psychotic and paranoid. There were no mental health rooms available in the Emergency Department due to them being occupied by other patients and so Charles was put in a cubicle near to the nursing bay (cubicle 7). This was more exposed to the busy Emergency Department and so potentially more detrimental than if he had been in a quiet room specifically for patients suffering a mental health crisis.

The plan being if Charles wanted to leave the Department, a capacity assessment would be carried out and if he then left Department the missing person alert process would be instigated with the police. Charles was assessed and agreed to an informal admission to a mental health unit. Charles was awaiting a bed to be made available and remained in the Emergency Department in the cubicle. On the morning of 13 March 2025 at 2am he was suffering with increased agitation and displaying psychotic symptoms; at 2.25am a capacity assessment was carried out where he was deemed to lack capacity; at 3.30am and at 4.22am he left the hospital but was returned on both occasions and he attempted to leave on several occasions thereafter; at 7am he was calm and administered medication. A short time after 8am Charles again left the department stating he was going to take his own life. Merseyside Police were contacted by staff at Arrowe Park Hospital to report Charles had been pursued by security officers into the woods. A short time later Charles was found deceased hanging in a wooded area, near to Arrowe Brook Lodge, near to a public car park off Arrowe Brook Road. He was hanging by an electrical cable hooked over a broken
branch. The toxicological analysis revealed nothing of significance and the post mortem found Charles died by hanging.

Throughout this period there were no legal powers to forcefully detain Charles within the emergency department. It is more likely than not that if a mental health bed had been available within a reasonable time, namely a few hours, the outcome for Charles would have been different and prevented him from leaving the Emergency Department and carrying out the act of self harm he subsequently did.

1. The legal powers and resources available for mental health patients in the Emergency Department of Hospitals is limited and as such detrimental to those attending Accident and Emergency Departments when suffering from a mental health crisis.
2. The severe shortage and availability of beds in mental health facilities resulting in vulnerable patients being left in the Emergency Department for days increasing the risk of self harm and death.