Daniel Jeffrey Moran · Prevention of Future Deaths report

On the 18ᵗʰ July 2019, I commenced an Investigation into the death of Daniel Jeffrey Moran, born on the 20ᵗʰ November 1986. The Investigation concluded at the end of the Inquest on the 08ᵗʰ January 2020.

The medical cause of death was: -

Ia. Hanging

The Inquest conclusion was, The deceased died as a consequence of injuries sustained from self-application of a ligature. He left notes expressing his intention to end his own life. Despite multiple suicide attempts in the period leading up to his death, he was not deemed suitable to be detained under the Mental Health Act. If the deceased had been detained under the Mental Health Act, he would not have had the opportunity to partially suspend himself from a window on the date in question.

The deceased was pronounced dead on the 14ᵗʰ July 2019, at his home address of ████████ Bolton, having used a rope as a ligature to partially suspend himself from a window. The deceased left goodbye notes expressing his intentions to end his own life. The deceased had a complex medical history including depression and alcohol misuse and had attempted to end his own life on multiple occasions in the period leading up to his death. The deceased was taken to hospital on 11ᵗʰ July 2019 due to a suicide attempt. On 12ᵗʰ July 2019, the deceased was admitted to hospital as a voluntary patient. During this period, he became aggressive and agitated and requested self-discharge from hospital. He was assessed as not meeting the criteria to be detained under the Mental Health Act and self-discharged from hospital, contrary to medical advice and was found dead on the above date.

During the Inquest, evidence was heard that: -

1. Staff were unaware of the situations where it was appropriate to breach patient confidentiality and notify family or friends, when concerns arose regarding patient safety/welfare.
2. Ward staff needed to have a greater understanding of how to prioritise new admissions and ensure the better flow of patients through the ward
3. Ward staff and ward doctors need to have a greater understanding of each other’s roles and responsibilities in relation to managing patient risk and whose responsibility it is to authorise leave and ensuring contemporaneous documentation are kept in relation to the decision making rationale (documenting any changes in risk and capacity).
4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale.

I request that you undertake a review to ensure staff receive the appropriate training on the issues identified above.