19 December 2018

Before HM Assistant Coroner Diane Hocking     
Leicester City and South Leicestershire Coroners Court
10 - 14 December 2018

David Stacey, 67, died on the morning of Monday 27 November 2017, just hours after being assessed by a Leicestershire mental health team. The inquest concluded on 14 December and found that his death was as result of a Road Traffic Accident contributed to by neglect. David was left alone in distress by a mental health team who believed he should be taken to a mental health hospital, but wrongly thought there were no beds available.

The evening before, David began experiencing hallucinations. Neighbours called Leicestershire police who attended and requested a Mental Health Assessment Team from Leicestershire Partnership NHS Trust.  David was assessed at his home at about 4.30am. He was suffering an acute psychotic episode for the first time. He believed that he was a highly trained secret operative who had protected the royal family and that he was being hunted by the IRA. The mental health team found he should be detained and admitted to hospital, for assessment under the Mental Health Act 1983 (Section 2).

However, they were unable to complete their application to take David to hospital, as it was their understanding there was no bed available. The mental health team left David alone in his house for some 45 minutes after deciding he should be detained, on the basis of his threatening behaviour. The inquest heard evidence that in fact there was a bed available and that had not been communicated to the assessors.

The Lead Psychiatrist in the mental health team stated that if he had been aware that a bed was available, as he should have been, they would have waited with David until the arrival of the ambulance. The inquest jury determined that David’s behaviour did not justify them leaving him on his own for what would be an unknown period of time; particularly given their understanding that no bed was available and once they had left a warrant would be required for re-entry (under Section 135 of the MHA).

The Mental Health Assessment Team found David’s risk of leaving the property as low, but must have assessed his overall risk of being left in the community as high or mental health detention would not have been warranted. Later that morning, David left his property driving his car at very high speed causing a road traffic collision involving a number of vehicles and resulting in his death only.

The police had attended prior to the mental health assessors, spending some four and a half hours with David in his home. The Police left the property upon arrival of the assessors and the jury found there was no reason for them to stay or return.

The coroner will be issuing a Prevention of Future Deaths report. This inquest is the third this month to find that neglect contributed to the death of a person in the care of mental health professionals.

Helen Robson, David’s cousin, said: “We as a family are pleased with the conclusion arrived at by the Jury. The family had two objectives, firstly, to find out what happened to David and his interaction with services before he died and secondly, what had the authorities done to make sure this doesn’t happen again. These were explored and answered through the inquest process and we are heartened that the Coroner has decided to exercise her powers under Regulation 28 to try and ensure steps are taking to prevent this happening again in the future.”

Deborah Coles, Director of INQUEST said: “This is a case where the positive actions of police and arrival of a mental health team could have meant David was kept safe. Yet he was wrongly left alone by mental health assessors, in a state of distress, because of a disjointed assessment and miscommunication about availability of beds.

It is a dire situation that mental health care provision is such that those in urgent need of care are left in danger and, as the jury confirmed, neglected. This is one of a series of damning inquest conclusions on deaths of those in the care of Leicestershire Partnership NHS Trust. Urgent action is needed from government and the CQC to ensure those in Leicestershire can access appropriate mental healthcare and are protected.”

Kelly Darlington of Farleys solicitors who represented the family said: “This is a very tragic case in which the outcome could have been prevented had there not been any failings in communication regarding the availability of a bed and the mental health team leaving David in the property alone.

The Coroner intends to issue a Regulation 28 Prevention of Future Deaths Report pertaining to the failure of the Care Commissioning Group pursuant to it’s failure under section 140 of the Mental Health Act 1983 to provide the Local Authority within it’s area of the arrangements for the reception patients in cases of special urgency.”



For further information and to note your interest, please contact Lucy McKay on 020 7263 1111 or email  

INQUEST have been working with the family since July 2018. The family is represented by INQUEST Lawyers Group members Kelly Darlington of Farleys Solicitors LLP and Andrew Bridgeman of St. John's Buildings Chambers.

The Independent Review of the Mental Health Act 1983 was published on 6 December by the Department for Health and Social Care. The report puts forward a series of recommendations aimed at modernising the Mental Health Act and improving the experiences of those detained. See the INQUEST response for more information.