Christian Barry · Prevention of Future Deaths report

On 31 January 2025 an investigation was commenced into the death of Christian Barry. The investigation concluded at the inquest on 16 September 2025.

The conclusion of the inquest was: Suicide

The medical cause of death was: Ia) Hanging

The Deceased, who had a past medical history which included excess alcohol use and recent alcohol withdrawal, was found hanging in a bathroom on 6 January 2025 at the respite facility where had been staying since 3 January 2025 and was pronounced dead at the scene.

The Deceased had developed physical and mental health symptoms from alcohol withdrawal and had suffered a worsening of his mental health symptoms in December, which resulted in a psychiatric assessment at hospital and a referral for intensive home based treatment.

Following an impulsive overdose of ████████ on 26 December 2024, the Deceased was admitted to hospital on 28 December 2024 and underwent a further psychiatric assessment and was discharged to a respite facility on 3 January 2025, as an alternative to continued hospital admission, under the care of the intensive support service.

The Deceased received a visit from the intensive support service on 4 January 2025 and concerns about the Deceased's confusion were raised with the clinical team by staff at the respite facility.

No visit took place on 5 January 2025 due to adverse weather conditions, which meant that the 48 hour review did not take place.

There is no recorded documentation of any communication between the clinical team and the staff at the respite facility as to the Deceased's presentation or level of risk on 5 and 6 January 2025, and no plan for the 48 hour review to take place on an alternative date.

No pre-death communications were discovered, but 1 am satisfied that the Deceased applied a ligature, ████████ with the intention of ending his life.

Death was certified at 12.04 on 6 January 2025 in Leeds.

There remains no system for formal communication, sharing and handover of information about patients who are admitted to the respite facility operated by Leeds Survivor-Led Crisis Service, but remain under the clinical care of the Intensive Support Service at Leeds and Yorkshire Partnership Foundation Trust. It was candidly accepted in evidence that there needs to be an improvement in communication channels and information sharing for the partnership to run efficiently and effectively and to mitigate risk.