Adam GALLAGHER · Prevention of Future Deaths report

On 21 October 2021 I commenced an investigation into the death of Adam GALLAGHER.
The investigation concluded at the end of the inquest . The conclusion of the inquest was

Adam GALLAGHER died due to his own actions whilst under the influence of alcohol to
which a missed opportunity for urgent intervention contributed.

1a Pressure on the Neck

1b Hanging

1c

II

Adam Gallagher was 30 years old. He had a history of Mental health issues and alcohol
Dependence Syndrome. On 17th October 2021 whilst under the influence of Alcohol he
communicated suicidal ideation by text message to a friend who shared this information and
details of his mental health history, including previous hospital admission under MHA 1983
with NEAS via 999call.

NEAS Health Advisor contacted AG by telephone; the call was short ,only limited
assessment of his Capacity and Risk was undertaken, No Clinical input was sought and
Ambulance was NOT dispatched.

At around 9am on 18th October AG was found ████████
where his death was confirmed.

(1) NEAS Trust confirmed in evidence that a more detailed assessment of AG should have
been undertaken and Clinical input sought leading to Ambulance dispatch and potentially an
alternative outcome for AG. Learning from the incident was limited to 'discussion' with 2 staff
involved.

Serious events of this nature should be subject of Trust wide learning and training to prevent
future deaths.

(2) Comprehensive retraining is required for those directly involved.

(3)An urgent review of Trust policy/protocol for handling/management of mental health
related incidents should be undertaken and associated training in respect thereof.

(4)Trust to review the events leading to AG's death and identify any additional safeguards
they may put in place to prevent future deaths.