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Investigation and inquest
On 3 August 2021 I commenced an investigation into the death of Daniel Clements, aged 27. The investigation concluded at the end of the Inquest on 13 July 2022.
A conclusion of suicide was recorded based upon a cause of death of 1a Multiple Injuries.
Circumstances of the death
Daniel Clements aged 27 was a troubled young man.
On Monday 19 July 2021 he was taken to hospital by the police and underwent a psychiatric assessment that afternoon. He was deemed not to be suffering from a mental illness and was discharged to his GP.
At 20:45 hours the same day he ran into the path of a fast-moving train and sustained fatal injuries.
Coroner’s concerns
(1) How can a person displaying suicidal ideation be kept safe, if deemed not to be mentally ill?
(2) Daniel Clements was a troubled young man aged 27. He had a low IQ, little education and was not fully compliant with his prescribed Risperidone medication (used to treat psychotic illness). He had always been dependent upon his mother, but when she was admitted to a care home in February 2021 (during the Coronavirus pandemic) he became homeless and adrift in society. In short, he was a vulnerable young man.
(3) In the fortnight before his death Mr Clements had the following interactions with healthcare professionals:
a) On 6 July 2021 he attended an A&E department and reported a deterioration in his mental health with symptoms of anxiety, inability to sleep, drug debts and homelessness, which were deemed attributable to his social situation rather than mental illness. He was referred back to his GP and advised to contact the police if he became concerned about his own safety. He was considered at that time to have the mental capacity to make choices affecting his social situation.
b) On 8 July 2021 he sought help from his GP and was referred to the Crisis Team (the Intensive Home-Based Treatment Team).
c) On 12 July 2021 his brother contacted the Single Point of Access to voice concerns about his mental state as Mr Clements was phoning him through the night and coming to his home. A representative from the Single Point of Access discussed with the brother options which included seeking an injunction against Mr Clements. He had sought a replacement prescription from his GP but had allegedly been refused an early issue of his medication.
d) On 19 July 2021 Mr Clements was brought by the police to the A&E Department at Pinderfields Hospital who referred him to the Psychiatrist Liaison Team. He was assessed by a registered mental health nurse and a Psychiatric Liaison Practitioner. They concluded he did not present with any symptoms indicative of an acute mental illness. He said in response to a direct question that he was “always suicidal”. Mr Clements was advised to collect his medication from the pharmacy, to work with housing, pay some of his drug debts and was given a leaflet outlining the Psychiatric Liaison Team Service.
(4) Mr Clements was passed between agencies without any lasting benefit. This tragic situation illustrates the void in relation to those with suicidal feelings without any overt psychiatric illness.
(5) The Secretary of State for Health and Social Care is asked to consider whether an extension to the Section 136 Mental Health Act 1983 power is required in order that a person such as Mr Clements could be detained for a few days in order to help him through a period of crisis. In this period a multi-disciplinary meeting involving the family, social worker, GP and psychiatric specialist might devise a plan to combat the social problems which otherwise devour the time of healthcare professionals without any conspicuous gain
Information checked against the published report and official responses