15 February 2024

This is a press release by Saunders Law, reshared by INQUEST

Before: HM Assistant Coroner Michael Wall 
Nottingham Coroner’s Court 
24 January - 6 February 2024 (10 days)

Daniel Tucker took his own life within hours of release from – but whilst still formally detained by – Highbury Hospital. The inquest jury concluded on 6 February 2024, that multiple failings admitted by the hospital Trust (Nottinghamshire Healthcare NHS Foundation Trust (‘NHCT’)), contributed to Dan’s death. 

Dan was just 24 when he died. He was a much loved brother and son, who was kind, generous, intelligent and thoughtful. He had a love for animals, and loyalty for those closest to him.

He died on 22 April 2022, within hours of his release home from Redwood 1 ward at NHCT-run Highbury Hospital, after ingesting a highly toxic substance he had purchased from a controversial website based in Canada, less than a month earlier. A person responsible for the website and providing the substance is currently under criminal investigation in Canada.

Dan had a diagnosis of Emotionally Unstable Personality Disorder. Dan’s admission to Highbury Hospital followed a 2-year period of relative stability, having had a relatively long admission before that, to a secure ward. He had commenced a biology degree with the Open University and was scoring over 90% in most modules. He was also working and maintained a strong and supportive relationship with a friend with whom he lived, and with his family. 

However, on 5th April 2022, after a recent relapse in his mental health, he seriously self-harmed and attended A&E with his friend. On 9th April, following a visit by the community ‘Crisis Resolution Home Treatment Team’ (CRHTT), he disclosed that he had a ‘plan’ and intention to end his life, and that he would be unable to keep himself safe in the community. Further to this, the decision was made that he met the criteria for detention under section 2 of the Mental Health Act.

Highbury Hospital gave evidence that from the outset of Dan’s admission, the plan was for a short crisis admission for Dan, for a period of assessment. Somewhat surprisingly, however, this ‘plan’ was not apparent from the Trust documentation disclosed during this inquest, nor from most of the witnesses’ evidence. 

Indeed Dan’s detention lasted only 12 days; and despite the plan for a period of assessment,  little meaningful assessment of his condition took place. In addition, he told staff very early in his admission, that he was finding it difficult to be on Redwood 1 ward, due to the emotional distress he was suffering arising from painful memories, relating to a traumatic previous experience on the same ward. Amongst other things, he had been badly assaulted there by another patient, which the ward were aware of. 

As such, Dan requested to be transferred to another ward and the Trust agreed with this care plan, taking initial steps to refer him to a different hospital. Unfortunately, however, the Trust failed to follow up on the plan to transfer him, despite the evidence showing there were beds available on another ward, to which Dan confirmed he would like to be transferred. In the meantime, the ward staff did not manage to engage with Dan for almost the entire period.

However, on 17th April 2022 he did open up to a Healthcare Assistant and expressed an intent to end his life.  Another specific expression of suicidal intent was noted in a handover note dated 20th April 2022 – 2 days prior to his release from the ward.

During the inquest the following failings were admitted by NHCT, regarding his final admission under their care:

  • There was a failure to update Dan’s ward specific Care Plan and Risk Assessment documentation in RIO during his admission.
  • More should have been done to try and effect the move from Redwood 1 to another hospital/ward in line with Dan’s wishes.
  • There was a failure to allocate a Named Nurse and/or a failure of the allocated named nurse to carry out a 1:1 session with Dan during his admission.
  • Dan had a Crisis Care Plan developed in August 2018 and updated in January 2019. There was a failure to update it in preparation for his discharge on 22 April 2022.
  • There was a lack of exploration in the Ward Round on 22 April 2022 and/or a lack of documentation of an exploration in the Ward Round of the “plan” that Dan had to end his life before his admission.
  • There was a failure by ward staff to hand over information regarding the expression of suicidal intent noted in the handover sheet from 20 April 2022 to the Ward Round on the 22 April 2022.
  • There was a failure to adequately discuss Dan’s risk with Dan’s carer prior to discharge.                                                                                 

In fact ward staff had not completed a formal Risk Assessment or Care Plan (at any point during Dan’s admission) which were accepted in evidence to be core documents. The evidence showed that when completed appropriately, for example, a Risk Assessment form should bring together a patient’s most up-to-date risk information in one central place. 

Particularly concerningly, senior clinicians gave evidence that they did not take those documents into consideration in formulating a plan for a patient’s care. Another witness gave evidence however, that the danger of not looking at the risk assessment (or indeed completing it) is that things will get missed. Things did get missed in Dan’s case.

The jury returned a narrative conclusion which included that:

  • There was no significant change in Dan’s mental state during his time in Highbury Hospital, nor in the level of risk that he posed to himself during that period.
  • An appropriate care plan was not put in place prior to or upon Dan’s release from the hospital.
  • He had a specific plan to take his own life when he was detained and admitted to Highbury Hospital, which he implemented following his release from Highbury Hospital.
  • He ingested the substance with the intention of ending his life.
  • There was a failure by the ward staff to engage adequately with Dan’s family and/or carers either during his admission on Redwood 1 and/or at the point of discharge.
  • There were significant risk related incidents or events during Dan’s last admission to Highbury Hospital and an associated failure by staff to make a proper record of the same, and a failure by staff to take appropriate action following them. These failures also contributed to Dan’s death.
  • There was no documented risk assessment regarding the decision to discharge Dan from Highbury Hospital. Such risk assessment as did take place failed to take proper account of all available, relevant information concerning Dan’s risk when making that assessment. That failure contributed to Dan’s death.
  • The following admitted failures contributed to Dan’s death:
    •  More should have been done to try and effect the move from Redwood 1 (the ward on which he was detained) to another hospital/ward in line with Dan’s wishes.
    • There was a failure to allocate a Named Nurse and/or a failure of the allocated named nurse to carry out a 1:1 session with Dan during his admission.
    • There was a lack of exploration in the Ward Round on 22 April 2022 and/or a lack of documentation of an exploration in the Ward Round of the “plan” that Dan had to end his life before admission.
    • There was a failure by ward staff to hand over information regarding the expression of suicidal intent noted in the handover sheet from 20 April 2022, to the Ward Round on the 22 April 2022.

In addition to this conclusion, the jury also heard evidence as part of the wider circumstances by which Dan came by his death, that the Responsible Clinician (‘RC’ - the consultant psychiatrist with primary responsibility for Dan’s care) had completed and backdated the ‘section 23’ discharge form, some days after Dan’s release from hospital. 

On its face, the s.23 written form by which Dan was discharged, appeared to be effective from 22nd April 2022. However, through the family’s sheer determination to obtain the truth regarding this aspect of the evidence, it transpired that the form was in fact completed and backdated on 25th April 2022. This is significant in that until that form was completed, Dan was not in fact formally discharged; he remained detained at the time of his death.

Even more shockingly, the RC gave evidence that his understanding of the law was such that Dan had been formally discharged from the care of Highbury Hospital, from the point at which he was physically released from the hospital. However, that is legally incorrect – formal discharge does not take place until a written ‘order for discharge’ has been made. 

The RC’s evidence came long after the Trust’s Head of Mental Health Legislation had ‘categorically’ informed the RC in writing, of the correct legal position – that Dan was not formally discharged by the time of his death. The family cannot be sure whether this advice was ignored, forgotten, or simply not agreed with by the RC. What it suggests however, is a level of incompetence and seeming arrogance at the most senior level of clinical responsibility for Dan’s care, in line with other shocking evidence heard during this inquest, suggesting a very concerning culture.

What is more, this mistaken position was initially given to the Coroner at a time when the Trust itself knew that Dan was still formally detained at the time of his death. This led the family who were none the wiser at that point, to undertake hours of their own research (prior to the instruction of their legal team) at a time of great distress, in order to be able to advance their case that this inquest should be conducted pursuant to Article 2, in their efforts to ensure a much more broad-ranging inquiry took place into Dan’s death. 

Fortunately, the Coroner was with them from the outset, however, in another case, such mistruths could easily lead a court to determine that Article 2 is not engaged, likely leading to a much less thorough inquiry into the death, and the family being left with far fewer answers to their legitimate questions arising from the death.

As a small consolation, the family have learned through this inquest, that this RC no longer works within the Trust’s inpatients service. However, it is understood he is still practising.

As well as Dan’s most recent admission to Highbury Hospital, the inquest scope included:

  1. The circumstances in which Dan came to take the toxic substance, including how and when he acquired it, and his intention at the said time;
  2. The EMAS response to the 999 call. In particular, was the original grading of the call appropriate given the reference to the ingestion of the specific toxic substance.

 The Coroner is currently considering whether to prepare a Report to Prevent Future Deaths.

The Coroner also confirmed he will be reporting two of the most senior clinicians involved in Dan’s care, to their professional regulator, in respect of serious concerns arising in this inquest. This includes the Responsible Clinician.

The conclusion in this inquest comes a matter of days after it was announced by the Government’s Health and Social Care Secretary that it has ordered a special review into NHCT, to be conducted by the CQC.  Further, per recent The Independent article, quoting from an email leaked to them, the Trust appear to have informed Highbury Hospital staff in December 2022: 

“We are saddened to report that over recent weeks it has been necessary to suspend over 30 colleagues due to very serious conduct allegations.

“These allegations have included falsifying mental health observations, as well as maltreatment of patients in our care”. 

Through this inquest, the family have also learned that criminal investigations into some staff members are ongoing in connection with the practice of observations (physical checks carried out on patients primarily aimed to ensure their and others’ safety and well being).

Dan’s family said: “The investigative journey has been filled with challenges, delays, inaccuracies, and a distressing absence of accountability from the NHCT. It was particularly disturbing to hear evidence from senior clinicians in charge of Dan’s care who continued to dismiss standard practice and procedures including evidence heard contradictory to Trust policies and even the law.  

We are so thankful to our Counsel, Rachel Barrett, and solicitor Clare Evans, for their dedicated and steadfast support in our quest to get answers for Dan and will be forever grateful for the Coroner’s commitment to lead a full, fair and thorough inquest with compassion and an unwavering focus on Dan as a person. 

As we grapple with the findings, our focus shifts to advocating for essential cultural changes, and emphasising the necessity for improved regulation on substances used in suicides. 

We have been devastated by our loss of Dan, a much loved, witty, intelligent, gentle soul who still had so much to give to the world despite periodic struggles with his mental health. Everyday we miss him and hope some light can be found by a shift in culture, ensuring vulnerable individuals receive the care they need.”

Clare Evans, Saunders Law, said: “The extent and wide-ranging nature of the failings in Dan’s case are shocking, showing that Dan’s tragic death was clearly avoidable. The announcement of a special review into the Trust is welcomed by the family. However, most important to the family now, is that true and deep-seated cultural changes are made at Highbury Hospital, especially given the senior clinicians’ approach towards the involvement of family and loved ones, and the risk assessment process, which raised particularly serious concerns”. 



For all media inquiries, please contact: Clare Evans at [email protected] or 020 7632 4300.

Daniel’s family were represented by Inquest Lawyers Group members Clare Evans of Saunders Law and Rachel Barrett of Cloisters.

Interested Persons (‘IPs’): deceased’s family, Nottinghamshire Healthcare NHS Foundation Trust (‘NHCT’), East Midlands Ambulance Service NHS Trust (‘EMAS’), and the Care Quality Commission (‘CQC’).

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