3rd March 2015

A jury at the inquest into the death of Chang Somers, a 36-year old man from Plymouth who was found dead in August 2012, has found there were major failings by Devon and Cornwall Police, South West Ambulance Service and community mental health services.

Following a week long inquest held at Torbay and South Devon Coroner's Court, the jury found that there was  miscommunication by all authorities concerned, a failure to prioritise a 999 call by police and alack of sufficient follow up as well as a lack of appropriate assessment of Mr Somer’s mental health condition.   

Mr Somers, also known as Valan Pitts, was a vulnerable man who suffered from schizophrenia and had learning difficulties. He was found dead on 22 August 2012 in a garden in Paignton, Devon after being reported missing by his family when he failed to turn up for a family celebration. He was last seen on 25 July 2012.

Prior to his death he had expressed concerns about his own mental health and his wish to be referred to a local psychiatric hospital. His family who had become increasingly worried about his behaviour and his fears that people were attempting to assassinate him, had requested he be assessed under section 3 of the Mental Health Act but this was never carried out.

The inquest heard that in the run up to his death Mr Somers visited numerous friends in Plymouth with one calling the police requesting he be sectioned by mental health services. IPCC investigators reported that on the day he went missing Mr Somers himself was in contact with police six times.

A man matching Mr Somers description was seen taking pills and collapsing behind a tree in a garden in Paignton on 25 July. The witness called 999 and ambulance and police services were asked to attend. On arrival paramedics searched the area but were unable to find Mr Somers, discovering only empty medication boxes. Police never attended the scene.

The dead body of Mr Somers was found almost a month later in an overgrown area of the same garden where he had been seen.

The jury reached a verdict of accidental death and noted a number of failings by the authorities concerned, specifically that:

the 999 call was not sufficiently prioritised

a follow up search was not carried out by police, and, importantly

a lack of follow up by mental health authorities leading to Mr Somer’s not being appropriately assessed when it was clear his health was worsening


The family of Chang Somers said:

“Chang was a joker; he had an amazing laugh which made everyone want to laugh with him. He was kind and generous, and had genuine charisma which drew people to him. However he was vulnerable and could be taken advantage of. He wanted a normal life, to live normally and to be happy: he was robbed of that.


In July 2012 we were very concerned that Chang’s mental health was deteriorated and we tried to have him assessed under the Mental Health Act. There were numerous opportunities after this point by the mental health services, the police and the ambulance service to help Chang. All of these opportunities were missed. Chang was let down by every service he turned to.  We welcome the jury’s findings of accidental death and failings by all authorities involved.

There needs to be a change of attitude not just a change of systems.

There needed to be one person Chang could rely on to support his mental health care, rather than leaving him to be responsible for his own care.

Moving forward, the authorities need to work together collectively to support vulnerable people. The links between these services need to be stronger. We have had to fight to have these failings recognised in Chang’s case.  Although we can’t bring Chang back, we feel strongly that no other family should have to go through this, to see their loved one die because of the kinds of failings in this case. One of the hardest things for us to come to terms with as a family is the fact that because Chang’s body was not found for so long, we will never really know how he actually died’


Deborah Coles, co-director of INQUEST said:

“The findings of the jury re-enforce the fact that agencies should work together to respond to someone in crisis.  The evidence at this inquest showed serious short comings in relation to the way the call handlers took calls from both Chang and his family which were at times disrespectful but also totally lacked mental health awareness.  We welcome the fact that four members of staff have been disciplined by Devon and Cornwall Police in relation to their conduct.  As stated before, it is shameful that a vulnerable black man was left to die in these circumstances. We want all the relevant agencies to seriously consider the findings from this inquest and make real changes as this is the only way to prevent a similar tragedy “


Trudy Morgan, the family solicitor from  Hodge Jones & Allen (HJA), said:

"The inquest found that the failings of the authorities contributed to Chang Somer’s untimely death. Those failings included serious miscommunication by various authorities, the 999 call not being correctly prioritised, despite it requiring an immediate response as a risk to life. A follow up search was not carried out. Finally a lack of follow up by mental health authorities led to Chang Somers not being sufficiently assessed when his health was worsening.

“Chang was a very vulnerable man who did not get the help he needed. The family want to ensure that lessons will be learnt and that authorities implement real and lasting changes as a result of this conclusion”

INQUEST has been working with the family of Chang Somers since his death in August 2012.  The family is represented by Inquest Lawyers Groups members Jocelyn Cockburn and Trudy Morgan of Hodge Jones and Allen solicitors and Jude Bunting from Doughty Street Chambersed families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.


IPCC's press release regarding their investigation can be found here: https://www.ipcc.gov.uk/news/ipcc-issues-findings-investigation-devon-cornwall-police-contact-man-prior-body-being-found