Stanislav Mucha · Prevention of Future Deaths report

On the 7th July 2022 I concluded the Inquest into the death of Stanislav Mucha who died on the 3rd February 2021 at Salford Royal Hospital.

The medical cause of death was recorded as :

1a) Polytrauma

The conclusion was a narrative conclusion – Died as a result of catastrophic injuries sustained after he jumped from the ████████ at the Rock centre in Bury. There was no evidence of his intention and he had a history of psychosis.

Stanislav was 17 years old when he died on the 3rd February 2022. In concerns had been raised about his mental health and he was admitted as an inpatient. He was diagnosed with acute-on-set psychosis. He was discharged from hospital in May 2020 and his care was passed to the Early Intervention team.

Stanislav presented as a high risk to others. He travelled to Slovakia with his family in September 2020 and he returned in January 2021. At this time there had been a clear deterioration in his mental health.

There are repeated attempts to engage him and referrals for a mental health act assessment. On the 22nd January the court heard that a mental health act assessment was attempted at the home address. In attendance was a Section 12 approved independent psychiatrist, a Consultant Psychiatrist from the treating trust, the Approved Mental Health Practitioner and a professional who was involved in sourcing a bed for Stanislav.

All members of this group gave evidence to the court as to what they understood had occurred on this day. There was a difference in opinion as to whether :-

a) A mental health act assessment had been conducted. The psychiatrists were of the opinion due to the brevity of time in which Stanislaw was observed, merely walking past them into the house, an assessment was not done. This was at odds with the AMP who believed an assessment had been conducted.

b) The next steps which were to be taken. Three of the professionals understood an application to the Magistrates court for a Section 135 warrant to allow entry into the property. This was not the understanding of the AMP who did not progress this action, having formed the opinion an assessment had in fact taken place.

The Court heard evidence the Psychiatrists were expecting a further attempt to conduct an assessment later that day or the next day.

On the 26th January 2021 Stanislav’s treating Consultant Psychiatrist became aware of the outcome of the mental health act assessment. Due to ongoing concerns in relation to Stanislavs mental health a further mental health act assessment was arranged for the 3rd February 2021.

Stanislav jumped ████████████████████████████████ of the 3rd February 2021.

1. The Independent Section 12 Consultant Psychiatrist did not make and the court heard does not have the facilities to make any notes in relation to their assessment.
2. Following the assessment on the 22nd January 2021 there was no documented agreement as to the outcome of the assessment between all professionals. This would have negated the confusion and lack of understanding as to what had occurred and the actions required.
3.