Sergio DUNKLEY · Prevention of Future Deaths report

On 27 August 2020 I commenced an investigation into the death of Sergio DUNKLEY aged 45. The investigation concluded at the end of the inquest on 06 May 2022. The conclusion of the inquest was ‘Suicide’

Sergio’s mental health deteriorated during 2020. He made threats to end his life culminating in his voluntary admission to a mental health ward at Hartley Hospital, Southport on 24th July 2020.
On his arrival at hospital Sergio was placed under regular observations, requiring that he be checked every 15 minutes. Upon being formally admitted, observations were continued at the same level until the following day when they were reduced to once per hour.
During his hospital admission Sergio received regular and appropriate input from ward staff and clinicians.
Sergio was last seen alive at approximately 12.30am on 18th August 2020. He was found to have taken his own life ████████ shortly before 01.30am on that same morning.
The Trust has made the following admissions:
The rationale for me change in Mr Dunkley’s observation levels on 25th July was not recorded.
The formal written risk assessment document commenced for Sergio on 25th July 2020 was not updated after 4th August 2020.
The following facts were found but were not directly causative of Sergio’s death on 18th August 2020
The hospital staff did not adequately record their rationale for assessment of Sergio’s risk of suicide between 4th and 17th August 2020.
On 17th August 2020, Sergio presented as significantly anxious when plans for his hospital discharge were being discussed, and there was a failure by staff to carry out a formal assessment as to whether he was at increased risk of suicide on that day.

(1) That there is no statutory requirement nor any current regulations which specifically require the doors within newly build mental health units to be fitted with ligature alarms.
(2) That whilst Health Building Note 03-01 as published by the Department of Health gives guidance that “ All fixtures and fittings should be ant ligature” the requirement to do so is not stated to be mandatory.
(3) That inspection and approval of newly built mental health units contains no mandatory requirement for the checking as to the placement of ligature alarms.