Richard Mark WHELAN · Prevention of Future Deaths report

On 19 December 2024 I commenced an investigation into the death of Richard Mark WHELAN aged 54. The investigation concluded at the end of the inquest on 02 April 2026 and the conclusion of the inquest was that:

Richard Mark Whelan's death was confirmed at 14.30 hours on 15 December 2024 at his property ████████. His death arose from exsanguination from incised wounds to both wrists. This was a deliberate act undertaken with the intention of ending his life although he subsequently made an attempt to rescue himself by leaving his property before collapsing on the pathway to his property. Subsequent attempts at CPR were unsuccessful.

In the preceding weeks before his death there had been a deterioration in his mental health. An assessment by a Mental Health Practitioner did not identify the risk to warrant either an admission to hospital or further support from Mental Health Services, but with the agreement of Richard ,who had capacity, a Crisis Plan was formulated which Richard chose not to use.

Richard Mark Whelan's death was confirmed at 14.30 hours on 15 December 2024 at his property 23 Greenacres, Sowerby Bridge. His death arose from exsanguination from incised wounds to both wrists. This was a deliberate act undertaken with the intention of ending his life although he subsequently made an attempt to rescue himself by leaving his property before collapsing on the pathway to his property. Subsequent attempts at CPR were unsuccessful.

In the preceding weeks before his death there had been a deterioration in his mental health. As assessment by a Mental Health Practitioner did not identify the risk to warrant either an admission to hospital or further support from Mental Health Services, but with the agreement of Richard, who had capacity, a Crisis Plan was formulated which Richard chose not to use.

In the time prior to his death, on 10 December 2024, he had disclosed that on 07 December 2024, he had taken an overdose with the intention of ending his life. On 10 December 2024, a neighbour had contacted his GP surgery expressing a concern for his welfare, resulting in the attendance at his address of two receptionists from the GP surgery and an ambulance crew. He had also been in close contact with a Neighbourhood Housing Officer. This resulted, with his consent, in a referral by the Neighbourhood Housing Officer to the Mental Health Trust Single Point of Access (SPA) Service on 11 December 2024. By the time of his death no action had been taken in respect of the referral. Evidence at the inquest suggested that a triage of any non-urgent referral may take up to 14 days and thereafter once triaged an initial plan to engage may be devised dependent upon the outcome of the triage.

Evidence at the inquest indicated that any referral to SPA classed as non-urgent may take up to 14 days to triage reflecting the SPA Standard Operating Procedure. The referrals to SPA could come from anyone, not necessarily someone with experience of mental health conditions. It was only following a triage of a referral and the outcome of the triage would a plan be devised to take forward a referral.