Michael Gerard McCrorY · Prevention of Future Deaths report

On 19th July 2013 I commenced an investigation into the death of Michael Gerard MCCRORy, Aged 50. The investigation concluded at the end of the inquest on 30th January 2015. The conclusion of the inquest was

Ia Multiple Fractures, Injuries & Burns

Michael Gerard McCrory intentionally ended his own life and the cause of death was aggravated by neglect.

At approximately 10.40 on the 16th July 2013 Michael Gerard McCrory died in a collision between his motor car, a Ford Kα and a tree on Lever Causeway in Bebington, Wirral. No other vehicle was involved in the collision and Michael McCrory was the sole occupant of his vehicle. It is found so as to be sure that he intended his death by his actions. The fact that this could occur ought to have been known by those caring for him, at the time, as a real and immediate risk to the Michael McCrory’s life and there were failings to take steps which might have been expected to avoid that risk.

Michael McCrory had suffered from a mental illness diagnosed as a Bipolar Affective Disorder since 1998, in spite of which he was a respected, high achieving professional teacher who had been stable with treatment in the community. Michael McCrory was honest, eloquent and clear in his communications with mental health professionals.

He self-reported to an emergency department and was admitted to in-patient treatment on the 12th January 2013 by the crisis team as a result of the manifestation of unmanageable suicidal thoughts. After 12 days he was discharged to outpatient care.
He had a brief second admission from 8th to 13th February 2013 and again continued with out-patient care. His third admission was from the 2nd to the 31st May 2013. Finally on the 8th July 2013 he was admitted having presented himself at the outpatient service with an overwhelming urge to end his life. He was admitted to manage risk of suicide as a voluntary patient initially on level 2 that is15 minute observations with only escorted absences from the unit, however the following day he was placed on level 1 - hourly observations whereby he could leave the unit with permission, the staff knowing his whereabouts when off the unit.

On the 13th July 2013 Michael McCrory reported to his wife, when she was visiting the unit that unknown to the mental health team he had left the unit taken a train from Spital Station to Eastham Rake and had considered throwing himself under a train. One reason for not doing so was out of consideration for the train driver. His wife reported this incident and these ideations to a nurse – however the fact that he had visited a train station was not understood by the mental health team - Michael McCrory was placed back on level 2 -15 minute observations the same day.

On the 15th July 2013 there was an emergency multi-disciplinary meeting for which Michael McCrory had prepared a clear but concise note of his explanation of his symptoms. He significantly stated, amongst other matters, “I do not want to kill myself, but suicide is a very attractive option when feeling this awful. Therefore I would like to stay ward based until such time as I start to feel better (I know I would be kept ward based anyway) – The professionals in the meeting did not read his communication and made a decision to reduce his observations to level 1. The reasoning for this change in observations is difficult to understand from the evidence but appears to be due to some concerns that Michael McCrory had been bored over the weekend and that the restrictions from the level 2 observations had a counter therapeutic effect giving him time to ruminate on negative thoughts. Michael McCrory’s wishes were overridden. On the 16th July 2013 Michael McCrory had left the ward with permission and had drawn cash from a machine by 09.15. He had gone home taken his car and by 10.40 he had died from the effects of the collision.

Given the eloquent, honest and clear communications he had with healthcare professionals though there was always a risk of a completed suicide, the long term risk of suicide could have been managed with specialist services and his support network with him receiving inpatient care as he requested when required. His death was facilitated and enabled in part by the fact that the poor standard of mental health on the 15th July 2013 had not been fully appreciated, his care, treatment and supervision was not adequate and he was not listened to; in particular from the general trust of the evidence the following were all more than minor or trivially contributory factors to a lesser or greater degree Michael McCrory’s death:

a. I report the above findings for your attention and comment with regard to action taken to prevent future deaths.

b. In addition clear evidence was heard that though the therapeutic observation policy had been amended the amended policy still required the whereabouts of a patient on level 1 observations to be known but the practice was still to just record that the person was O (off the ward) as opposed to (Out with permission from a specific time going to a specific location).

c. The inquest was heard in January 2015 and it was unclear from the evidence as to what training, support and professional development had been given to the staff involved and staff generally with regard to minimising the risk of recurrence of this type of tragic eventuality.