Neil Challinor-Mooney · Prevention of Future Deaths report

On the 29th November 2018 I commenced an investigation into the death of Neil Challinor-Mooney, age 51 years. The investigation concluded at the end of the jury inquest on 12th May 2021. The conclusion of the inquest was that Neil died as a result of suicide contributed to by neglect.

Neil Challinor-Mooney suffered an acute relapse in his mental health in late October 2018. He required admission to hospital under the provisions of the Mental Health Act on the 1st November 2018. Shortly after his admission to hospital, his trainers were removed from him as part of risk management. There was no documentation around the removal of the trainers. At some point during the course of admission to hospital (1st November to 16th November 2018 Neil’s trainers were returned to him. There was no documentation as to when the trainers were returned or any documentation around risk assessment or risk management relating to the decision to return the trainers. On the 13th November 2018 Neil disclosed in a ward round that he was having suicidal thoughts and that he would use his shoes to hang himself. The risk assessment and risk management plan was not updated as a result of this disclosure. Neil repeated this disclosure to a junior psychologist on the 14th November 2018. The psychologist disclosed the suicidal ideation and the plan to the senior nursing team. An action was documented for Neil’s shoes to be removed, but this was never carried out. On the 16th November 2018 Neil was found suspended by the laces of his trainers. He was in an unconscious state. Sadly, he passed away at Queens Hospital on the 18th November 2018.

The Inquest heard evidence that the Trust policy in relation to risk assessment and risk management is sufficiently clear, however the Court was not fully satisfied that the said policy had been fully embedded into practice. A number of nursing staff, including senior nursing staff, during the course of the admission, failed to follow the policy.

Another concern arising during the course of the Inquest related to the integrity of the electronic records. The Inquest heard that medical records should be validated very shortly after being entered into the system. The Court saw evidence of multiple entries where there was a significant delay between original entry and validation. Amendments were made to the records after Neil had passed away, but these were not apparent on the records disclosed to the Court. An audit of the records had to be carried out before the amendments were exposed.