Investigation and inquest
On the 7th of June 2016 I commenced an investigation into the death of Joshua James Alexander Hamill (DOB 23.7.91, DOD 5.6.2016). The investigation concluded at the end of the inquest on the 30th of November 2017 and a jury recorded a conclusion Misadventure with the cause of death being (a) Cerebral Anoxia with Oedema (b) Suspension 2. ADHD
Circumstances of the death
The Deceased was known to the Mental Health Team of Northamptonshire Healthcare, NHS Foundation Trust and had been known to self-harm on a number of previous occasions. In the early hours of the 5th of June 2016 his girlfriend raised a “Concern for Safety” with North Wales Police indicating that he was threatening to kill himself. Officers attended and re-categorised the matter as a domestic incident, focussing their attention on the welfare of his girlfriend. They left the Deceased alone shortly after 01.00 and he was subsequently found at Flint Castle later that morning where he had died as a result of hanging.
Coroner’s concerns
1. That the current training afforded to police officers in North Wales was ineffective in ensuring that they were able to accurately identify mental health issues in persons they were attending.
2. That when an event was opened as a “Concern for Safety” it was closed down as domestic incident without there being a recorded resolution as to safety and welfare of the person originally at risk of harm.