Mr Bromley · Prevention of Future Deaths report

On 6th March 2019, Alison Mutch OBE, Senior Coroner for Manchester South opened an inquest into the death of Ian Charles Bromley who was found dead on 18th February 2019, aged 52 years. The investigation concluded at the end of the inquest which I heard on 19th August 2019.

At the end of the inquest, I determined that Mr Bromley died as a consequence of hanging. I recorded a conclusion of Suicide.

Mr Bromley first presented to mental health services in January 2019, experiencing low mood and suicidal thoughts connected with a range of personal difficulties. Following an initial assessment, Mr Bromley was offered an informal admission to hospital, but declined this. Instead, he accepted a referral to the Home Treatment Team as an alternative to inpatient treatment. This continued in the guise of one-to-one sessions with a mental health practitioner, alongside antidepressant medication prescribed by Mr Bromley’s General Practitioner.

Mr Bromley was found dead on 18th February 2019 at his gym, having suspended himself by the neck with a ligature.

1. Despite the fact the Home Treatment Team purports to offer a genuine alternative to hospital treatment, it is a matter of concern that the Team does not currently have access to a dedicated Consultant Psychiatrist specifically allocated to the service;

2. Whilst the action plan which accompanied the Trust’s internal investigation made reference to plans to recruit to such a post, the manager from the service who gave evidence appeared unaware of any substantive recruitment process currently in train, let alone the timescales within which it might reasonably be anticipated the post will be filled;

3. Although interim measures are in place whereby practitioners in the Home Treatment Team can access a psychiatrist on a rota system, the court heard evidence that the operation and effectiveness of this measure is patchy, with much depending on the individual approach of the particular psychiatrist in dealing with queries from this team alongside their existing workload.