8 March 2023

Before HM Area Coroner Delroy Henry
Coventry Coroner’s Court
27 February – 7 March 2023

Edward Shirley, 36, died on 1 January 2022 after absconding whilst a mental health inpatient at the Caludon Centre in Coventry. An inquest jury has now reached an open conclusion.

Edward was from Nuneaton. A much loved son, brother and father, Edward liked music, motor racing and was extremely interested in space travel. Always concerned about others, his family say he was always checking in on them and trying to comfort them following the death of his younger brother in 2021.

Edward had schizophrenia and substance misuse problems. He had been under the care of Coventry and Warwickshire Partnership NHS Foundation Trust (CWPT) since 2006. He was repeatedly sectioned under the Mental Health Act.

Following the death of his brother Andrew, Edward’s mental health spiralled. On 11 October 2021, Edward was detained under the Mental Health Act at the Caludon Centre after refusing to take his medication.

Between 21 October and 30 December, Edward was granted escorted and unescorted leave. He absconded from the Caludon Centre four times during these periods of leave. Despite this, his leave continued to be authorised.

Edward’s father repeatedly raised concerns with the centre about his son’s welfare, his risk of absconding and the fact he was allowed escorted leave.

The last time his family saw Edward, he was worse than they had ever seen him before. He was extremely agitated, expressing psychotic ideation and told his family that he had been assaulted at the centre.

The family raised a formal complaint with the trust expressing concerns that if Edward absconded again, ‘he will come to serious harm’. The trust failed to substantively respond.

On 29 December, after Edward had absconded three times, his leave was temporarily withdrawn during a Multi Disciplinary Team meeting pending a review. Later that day, leave was reinstated by a clinician who was not present at this meeting.

On 30 December, at around 6:40pm, Edward absconded for the last time. At 7.20pm, Edward’s father was informed that he had absconded, and the police were notified at 9:03pm. The inquest jury heard that by this time, the “golden hour” in respect of missing persons investigations, had elapsed. Edward’s family received no further communication from the trust.

On 2 January, Edward was found in a canal. The inquest concluded that he died from immersion in water.

Edwards’s parents, on behalf of Edward’s family, said: “We would like to thank the jury for their careful consideration and for their conclusion.

Edward was our eldest son. He was vulnerable, unwell and grieving the death of our youngest son, Andrew. When his mental health started to deteriorate and he struggled to cope in the community, we thought he would be safe at the Caludon Centre and that he would receive the care he desperately needed.

We raised our concerns with the Caludon Centre about Edward’s multiple incidents of absconding from the ward, and the risk that he would continue to do so. We feared that he would come to harm if he did. But we were ignored.

We remain concerned that the Trust has not learned lessons from Edward’s tragic death.”

Tara Mulcair of Birnberg Pierce solicitors, said:Edward was consistently assessed to be a high risk of absconding from the Caludon Centre, yet his leave continued to be authorised. The inquest heard that Edward’s death whilst absent without leave is not an isolated incident.

Coventry and Warwickshire Partnership NHS Foundation Trust must take urgent steps to ensure that sufficient measures are in place to mitigate the risk of sectioned patients coming to serious harm, or death, when failing to return to the hospital after a period of leave. Edward’s family remain deeply concerned that these important lessons have not been learned.”  

Selen Cavcav, Senior Caseworker at INQUEST, said: “Edward needed care and support. This inquest raises serious issues about why Edward was able to abscond so many times from a place that was meant to keep him safe despite the repeated pleas from his family.  

We know that what happened to Edward is not an isolated incident. We see similar shocking failures across the whole country.  What is needed is a proper oversight of all inquest findings and recommendations and absolute commitment to put things right so that nobody else dies in similar preventable circumstances.”


For further information please contact Leila Hagmann on [email protected].

Edward’s family are represented by INQUEST Lawyers Group members Tara Mulcair and Ilaria Minucci of Birnberg Peirce solicitors and Robbie Stern of Matrix Chambers. They are supported by INQUEST Senior Caseworker Selen Cavcav.

Other Interested Persons represented include Coventry and Warwickshire Partnership NHS Foundation Trust (CWPT) and West Midlands Police (WMP).

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