13th December 2016

Before Senior Coroner Martin Fleming at Bradford Coroners Court


A jury at the inquest into the death of Christopher Cousins this week concluded that failures in communication, risk assessment and the delayed implementation of a psychiatric hospital’s Missing Persons Policy contributed to the circumstances surrounding the 34-year-old father taking an overdose of heroin.


The jury also found that there had been insufficient communication by the hospital with Chris’s family and with the police, which prevented an earlier response.


Chris was tragically found dead at home on 11 June 2015. He had been admitted onto South West Yorkshire Partnership NHS Foundation Trust’s acute psychiatric units four times during that year, after a significant deterioration in his mental health.


During his last admission on 22 May 2015, the jury heard that the hospital did not specifically record any risk assessment for suicide. This was despite Chris reporting suicidal thoughts and extreme hopelessness on several occasions when going out on leave from the ward. Chris’s care plan also made no provision to support Chris when he was on leave – when, according to the Coroner’s psychiatric expert Professor Keith Rix, it was evident that Chris was “at his most suicidal.”


On 6 June 2015 Chris went missing and returned to the ward late and intoxicated after his family had been contacted and managed to locate him. A ward doctor apparently decided that Chris’s leave would be stopped until he could have a full psychiatric assessment and evaluation of his risk. This was not properly communicated to other members of the nursing staff. No such assessment took place.


Chris was granted leave on 10 June 2015 by a nurse who was unaware of any previous incidents involving Chris or of the doctor’s decision regarding his leave. Chris did not return as planned. The inquest heard that following his failure to return, there were delays in the implementation of the hospital’s Missing Persons Policy, there was a failure to contact Chris’s family until the following day, and insufficient information was passed to West Yorkshire Police, leading to Chris’s case being inappropriately downgraded.


Notwithstanding their finding that Chris did have good therapeutic relationships on the ward, the jury returned a highly critical narrative conclusion, concluding that failures in communication, accessing important information in relation to Chris’s risk, failure to contact his family and a lack of clarity in the hospital’s policy all contributed to Chris’s death.


The Senior Coroner, Martin Fleming, has indicated that he will be sending a Report to Prevent Future Deaths to the Trust, in particular to address failures in communication on the ward and to the police to address circumstances where a patient goes missing, as well as inadequate recording of important information regarding a patient’s risk.


Chris’s sister, Donna Cousins, said:

“We wanted Chris to be on the Priestly Unit for his own safety. We always believed Chris was badly let down, because the nursing and medical staff did not believe he was as ill as he said. We are pleased that the jury has recognised the serious failures in policy, risk assessment and communication – particularly with us – which contributed to Chris’s death. If only the hospital had called us the night he went missing, we would have found him like we had before. We hope that, in response to the Coroner’s Prevention of Future Deaths Report, the Trust will make significant changes so that no more families find themselves facing a tragedy like we have”.


The family’s solicitor Leanne Dunne, said:

“Aside from the serious individual failings in Chris’s case, this jury has highlighted a dangerous policy failure. The Joint Missing Persons’ Policy developed between the NHS Trust and West Yorkshire Police was clear that nurses have a primary duty to do a home welfare check when a service user goes missing. The nurses in this case, however, said they had never undertaken this check and did not have the resources to do so. This dangerous gap in provision for vulnerable service users’ needs urgently to be addressed so that no more families are put in this position”.


Deborah Coles, Director of INQUEST, said:

“Failures in information sharing between medical staff and state agencies, combined with poor communication with families is a serious concern across NHS Trusts, as evidenced by the CQC report which was launched today. In Christopher’s case, had the hospital involved the family when he went missing, the outcome could have been very different. Health trusts must recognise the valuable role families can play in the care and support of vulnerable patients”.



INQUEST has been working with Chris’s family since immediately after his death in June 2015. Chris’s family are represented by Inquest Lawyers’ Group solicitors Leanne Dunne and Alice Stevens of Broudie Jackson Canter, and barrister Tom Stoate, of Garden Court Chambers.








For further information, please contact: Shona Crallan at [email protected] or Gill Goodby at [email protected]


Leanne Dunne at Broudie Jackson Canter can be contacted for a more detailed case history on [email protected] or 0151 227 1429.



INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.


Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.