Ben Alan SHIPLEY · Prevention of Future Deaths report

On 03 September 2019 I commenced an investigation into the death of Ben Alan SHIPLEY aged 22. The investigation concluded at the end of the inquest on 23 February 2023. The conclusion of the inquest was that:

Ben Alan Shipley died on 29th August 2019 having been struck by a train at Milne Viaduct East End after absconding from Huddersfield Royal Infirmary's Clinical Decisions Unit at 12.30. Ben voluntarily came to A&E on 28th August 2019 at 19.27 after suffering a mental health crisis. He was assessed by 2 mental health psychiatrists and a mental health nurse. He was deemed to require a section 2 detention under the Mental Health Act, but was to remain in A&E for his own safety until a bed was sourced. After a prolonged search, using various communications methods, for a bed lasting approximately 17 hours, Ben absconded from A&E, where he traveled to a railway,████████

Ben is a 22yr old single man who lived with his family in Lepton, Huddersfield.

On the 28th August Ben was seen by his GP who referred Ben to the 'Single Point of Access' service. On the 29th of August Ben was at the hospital with his parents, waiting to be sectioned under the mental health act when he ran away. His parents reported him as a missing person.

That afternoon Ben was struck by a train in a rural area of Huddersfield. His life was pronounced extinct at 14:14hrs.

Ben was assessed at 22.00 on 28th August 2019. It seems to me that there are about 12 hours of delay following a 22.00 assessment Health Act assessment built into the system if there is no bed. Presumably this would be longer if Ben had been assessed earlier in the night shift. I am told beds do not become available over night. This means Ben cannot be legally detained as the section 2 is not complete until there is a bed. He is therefore subject to the goodwill of the A&E (who are not trained in mental health) and the goodwill of the family (who are similarly not trained in mental health). ████████

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