02 August 2021

Before HM Assistant Coroner Sonia Hayes
Oxfordshire Coroner’s Court
Final hearing 26-30 July 2021

Adam Stanmore, a 37 year old man of mixed heritage from Oxford, was found dead on 13 June 2019. He had a history of self-reported depression and had type 1 diabetes. An inquest has today concluded that multiple failures by the police, paramedics and mental health services contributed to his death, including the decision of paramedics to delete records which indicated that Adam had taken an overdose of insulin to kill himself.

On 23 April 2019, Adam contacted his GP and reported paranoid thoughts and hearing voices telling him to kill himself. Adam was referred by his GP to the Oxford Health NHS Foundation Trust Mental Health Team and was seen on the same day. Following assessment, Adam was given a post-it note with the telephone number of MIND and told to go back to his GP for antidepressant treatment.

On the morning of 18 May 2019, Adam left his mother’s house leaving a note stating that he “had enough”. In the early afternoon he obtained a knife from a neighbour who called Thames Valley Police out of concern for his welfare. Adam was found by Thames Valley Police sitting on his own on a fence. He was quiet and staring ahead. Adam told them “I want to kill myself.”

Armed Response Officers then arrived and approached Adam. They took hold of Adam and saw there was a knife in his waistbelt. As an officer was removing it, Adam put his hand on it.  The police then discharged Taser on three occasions and used force to restrain Adam and remove the knife from him. He remained prone on the ground with leg restraints until the arrival of the police van.

Adam was then taken into Abingdon Police station. On arrival he was barely conscious and his blood sugar levels were critically low. He again told police that he wanted to kill himself. South Central Ambulance Service was called to convey Adam to the hospital for physical and mental health assessment and treatment. No further action was taken in relation to his arrest. The evidence of the paramedics was that they were not made aware that Adam had told police officers that he wanted to kill himself.

During the journey in the ambulance, Adam told the paramedics that he had overdosed on insulin to try and kill himself.  This information was recorded. It later was deleted and only came to light during the Inquest.

Adam was allowed to leave the ambulance before it reached the hospital. No mental health capacity assessment was carried out and Adam refused any additional treatment or checks of his blood sugar levels. Paramedics then provided information to police and central control that Adam was fully recovered.

Police located Adam a few hours after he had left the ambulance but were reassured by a lack of markers in their own system and by the information provided by the paramedics. Oxford Mental Health street triage decided that they would not perform a face to face mental health assessment on the basis of the information from police officers that Adam seemed fine.

Adam was last captured on CCTV at around midnight, after police had left him. Adam's body was found on 13 June. He had a ligature around his neck and was surrounded by insulin boxes. It was likely that he died near the time he was last seen.

The inquest jury have today concluded that Adam died of suicide by hanging and/or hypoglycaemia. They found that the circumstances which contributed to Adam’s death were that:  

  • He did not have appropriate psychiatric follow-up and there were risks of self-harm and suicide which were not appropriately assessed and managed by the Adult Mental Health Team.
  • There was an inappropriate handover of information between SCAS control and the paramedics dispatched to Abingdon Police Station and between police custody and paramedics at Abingdon Police Station
  • There was some lack of clarity in the handover between healthcare and paramedics at Abingdon Police Station.
  • The attending paramedic should have carried out a formal mental capacity assessment and additional risk of self-harm assessment when Adam informed them that he had taken an overdose of insulin with the intention to kill himself. This information should have been escalated when Adam refused to have his observations checked or be conveyed to hospital.
  • Deletions from the ambulance electronic patient record meant that significant information was not visible to healthcare professionals. These issues impacted on the perception and assessment of presenting risk to Adam’s physical and mental health.
  • The failure of the attending paramedic to share information on more than one occasion contributed to Adam’s death
  • There were issues with information sharing about Adam on 18 May between various agencies which in combination contributed to his death.

Laura Klee, Adam’s ex- partner, said: “The conclusion marks the end of what has been an agonizing two year wait for answers surrounding the death of our dear Adam. It is with great sadness that we face the end of this inquest without Adam’s mother, Sandra, who passed away only 8 weeks ago, and who will never know the answers she so desperately sought regarding the death of her son.

While we were already aware that there had been failings in Adam’s care, we were not fully prepared for some of the evidence that came to light. We have been truly shocked and saddened by the blatant disregard shown towards Adam in his final hours by those who could have saved him, in particular the ambulance crew. We can only conclude that a great number of people involved in Adam’s care that day simply did not care.

We truly believe that there was no part of Adam that wanted to end his own life that day, but due the psychosis he was experiencing, felt he had no choice. As a family, this has never been about blame or finger pointing, but about finding answers to something that has been incredibly difficult to process. We hope mostly that learning will be done and from this and other’s lives may well be saved.

While the stigma surrounding mental health is slowly lifting among the population, we as a county have a long way to go in ensuring that our emergency services are able to understand mental health and offer the support that people require, in particularly with regards to the understanding of mental health within the police force.

We cannot bring Adam back to us, but we sincerely hope that his death will not be in vain. His daughter faces growing up without her father, but we will always be sure to tell her about what a hero her Daddy was.”

Chanel Dolcy of Bhatt Murphy solicitors, who represent the family, said:” Adam made repeated efforts to get help even when he was in the throes of a mental health crisis. Those whose duty was to give him that help repeatedly turned him away and failed him. His admission that he had taken an overdose of insulin in an attempt to kill himself was ignored. The catalogue of errors by various agencies who came into contact with Adam is shocking and disheartening.  Adam’s sad case has very clearly shown the stark defects in the systems that are in place to protect the most vulnerably in society.”

Selen Cavcav, Senior Caseworker at INQUEST, said: “It is utterly shameful that Adam was left to die in these circumstances and basic standards of care necessary to protect those in distress fell by the wayside as they did. This  inquest highlighted yet again systemic issues around how the agencies respond to people with mental ill health”


For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

Adam’s family are represented by INQUEST Lawyers Group members Chanel Dolcy of Bhatt Murphy solicitors and Kirsty Brimelow QC. The family are supported by INQUEST caseworker Selen Cavcav.

Other Interested persons represented were Oxford Health NHS Foundation Trust, Thames Valley Police, South Central Ambulance Service, Mountain Healthcare (who reviewed Adam Stanmore in police custody) and Berkshire Healthcare NHS Foundation Trust (who also reviewed Adam Stanmore in police custody).

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.