Steven Clive Cooke · Prevention of Future Deaths report

On 18 July 2019 I commenced an investigation into the death of Steven Clive Cooke, aged 56. The investigation concluded at the end of the inquest on 16th December 2020. The conclusion of the inquest was Steven Cooke was found, having passed away, on the 9 July 2019 at his home address of 1a Springfield Grove, Stoke-on-Trent, ST8 7BA. He hung himself by a ligature fashioned from a grey wiring cable fastened to the rafters in the loft. The cause of death recorded at inquest was:
1a) Hanging by ligature.

Steven Cooke first presented to the Mental Health Services within Stoke-on-Trent on the 1 February 2019, after the breakdown of his marriage of 36 years. He was treated as an inpatient and within the community for this, until he passed away on the 9 July 2019. During the inquest it was accepted by the Trust that work was needed nationally regarding gaining input from a patient’s family. Whilst it was accepted that patient’s wishes for information not to be passed on had to be respected, this did not stop the Mental Health Services engaging with families to find out further information regarding a patient.

Whilst Stoke-on-Trent Mental Health Services are mandated to engage with families of a patient to ascertain as much information as possible, this does not happen nationally. There is little in the way of national guidance and it will often depend on which area you live in, as to whether this takes place.
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(1) That there is no national guidance regarding engagement with the family of a Mental Health patient to gain as full a picture as possible.