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Investigation and inquest
On the 13th June 2014 I concluded an Inquest into the death of Liam Hardy, a 15 year old schoolboy. The medical cause of death was hanging, and I recorded a narrative conclusion as follows:
At about 9 pm on 19th November 2012 at his grandfather’s home (████████).Liam became upset and agitated while exchanging text messages. He tied his school tie around his neck and attached the other end to the upper part of a bunk bed. He sat on the lower bunk and the ligature caused him to lose consciousness. On the balance of probability he did not intend to die. His actions were in part because his complex behavioural and emotional problems were not adequately or appropriately assessed or managed by social and mental healthcare services, and the risk to his life by acts of self harm was not recognised or adequately managed. There were failures to fully share or access information, and significant events were not dealt with in a timely fashion or at all. The services placed too much reliance on addressing his needs through the family therapy service who failed to acknowledge that their intervention was not effective in addressing Liam’s needs. Other agencies did not appreciate the role and limitations of the family therapy service with the consequence that alternative and/or additional measures to protect Liam were not fully explored or considered.
Circumstances of the death
Please see the conclusion set out in paragraph 3. Further information can be provided if required.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
The nurse who assessed Liam after an episode of self harm was unaware of some of the significant events in Liam’s history. She explained that the RiO system (an electronic patient record system used in many Trusts) did not flag up or summarise such events or primary concerns and issues in a single place, and there was insufficient time to read all of the notes (which might be voluminous) before seeing a patient. Had she been aware of the full history her actions may have been different in Liam’s case, but her comments about the RiO system were general, and the difficulties are apparently encountered even today.