Investigation and inquest
I concluded the inquest into the death of Girmaye Guyo Liban on 17th May 2023 and recorded that he died from:
1a Drowning
I returned an Open conclusion following investigations.
Circumstances of the death
The Deceased had a long history of mental health illness and substance abuse. Between 4th June 2020 and 15th September 2020 he was detained pursuant to the provisions of Mental Health Act 1983 at Eagleton Ward, Meadowbrook Unit.
The Deceased’s discharge from Eagleton Ward was authorised via his mother using her Nearest Relative Powers pursuant to the provisions of Mental Health Act 1983, and its associated Code of Practice. The Deceased then returned to the family home.
The evidence that I heard at the Inquest was such that the Deceased was still liable to be held under Section 3 Mental Health Act 1983; however, due to the difference in the test being applied for consideration of an application by a Nearest Relative, there was no choice but to discharge the Deceased. Further evidence alluded to the concerns from clinicians about this power, and although the evidence was that it is seldomly used, it presents an opportunity for patients and families to deviate from the clinical course prescribed by clinicians.
There was no consideration for a Community Treatment Order for the Deceased as the provisions of the legislation refer to discharge from detention.
The Deceased remained unwell in the community, and on 10th November 2020 he went missing. His body was found in a local reservoir on 26th November 2020. There was insufficient evidence to determine how he came to enter the water.
Coroner’s concerns
The Nearest Relative Power may (as it did in this case) present an opportunity for a patient and/or their Nearest Relative to apply to the Responsible Clinician for discharge in circumstances when the patient remains liable for their continued detention. There does not appear to be a thorough procedure or legal test for clinicians to apply, and thus there is a risk that Responsible Clinicians may be faced with circumstances whereby a patient will be discharged from hospital despite them continuing to meet the criteria for detention.