Daniel Robert Nelson · Prevention of Future Deaths report

On 21st May 2020 an investigation was commenced into the death of Daniel Robert Nelson aged 37. The investigation concluded at the end of the inquest on 12th September 2022. The conclusion of the inquest was that the deceased died as a result of heroin toxicity, that his death was drug related and that failings of the Trust in relation to among other things, section 117 obligations, contributed to the death.

The deceased had a long history of a dual diagnosis of schizophrenia and drug dependency. Following years of homelessness and imprisonment he was sectioned under section 3 of the Mental Health Act 1983 (“the Act”) and received treatment in the Eagleton Ward of the Meadowbrook Unit in Salford. He was discharged from section 3 care with an inadequate discharge plan and the requirements of section 117 of the Act were not met. He was housed in unsuitable emergency accommodation, without adequate support, in circumstances where he had access to drugs and subsequently died as a result of an accidental heroin overdose. The evidence revealed that with proper discharge planning and care his death would probably have been avoided. Staff on the Eagleton Ward had insufficient knowledge in relation to discharge planning and duties, particularly where, as in this case, the discharge was to an area outside Manchester. Within the Trust there was no protocol, policy or adequate standard operating procedures governing section 117 discharges

Within the Trust there was no protocol, policy or adequate standard operating procedures governing section 117 discharges