21 October 2019

Before Assistant Coroner Jonathan Heath
Northallerton Coroner’s Court
14-16 October 2019

The inquest into the death of Isaac Lawrence Eastwood, 21, has concluded with the coroner finding that on 19 July 2018 Isaac fell from a height, suffering unsurvivable injuries, and he intended to end his life. He was receiving care from mental health services, Tees Esk and Wear Valleys NHS Foundation Trust, at the time of his death. The coroner did not make any criticism of these services in his conclusions, despite the critical evidence heard at the inquest.

Isaac was from Leyburn, North Yorkshire. His family described him as having a passion for travel and being thoughtful and kind throughout his life. They told the inquest that Isaac was super fit and enjoyed climbing, skate boarding, running or canoeing on a daily basis.

Isaac became involved with mental health services very briefly as a child in 2014 and 2015. In 2017 he was sectioned under the Mental Health Act after experiencing a manic episode and was diagnosed with Bipolar Affective Disorder in July 2017. Despite three requests from the family for admission to hospital between June and July 2018, his level of care was deemed suitable to be dealt with in the community.

The two day inquest heard evidence that on 10 July 2018 Isaac was assessed by both his care co-ordinator and the Crisis Team. It was agreed that Intensive Home Treatment was required and he was placed on ‘red risk status’ to monitor his risk. However, two days later his risk status was reduced. It was accepted in evidence that Isaac should have been on daily intervention for at least 72 hours. 

Evidence was heard that on the 16 July 2018, three days prior to Isaac’s death, his care co-ordinator recommended that he be admitted to hospital due to a decline in his mental health. However the Crisis Team did not agree. They contacted Isaac that evening via telephone but did not insist on seeing Isaac the next day for a face to face review. Throughout the evidence it was accepted by some of the clinicians that they perhaps should have liaised more with Isaac’s family.

On the 18 July 2018 Isaac received a visit from Tees Esk and Wear Valleys NHS Foundation Trust who changed his diagnosis in relation to his mental ill health. The inquest heard that Isaac was shocked and upset by the change. His family were left to deal with this news and the effect it had on Isaac. Isaac was pronounced dead at 6.21pm the next day.

Despite the coroner initially accepting that the inquest should be held in line with Article 2 requirements (relating to the duty to investigate deaths where the state had a responsibility to protect the person’s right to life), after hearing all of the evidence, the coroner confirmed that an Article 2 conclusion was not appropriate. His decision was based on the fact that Isaac was not under the control of the state at the time of his death, the real and immediate risk to Isaac’s life was not present and the errors made by individuals did not amount to systemic failure.

Isaac’s father, Simon Eastwood said: “As a family we feel we have honoured the memory of our beloved 21 year old son and feel the inquest process has allowed the issues to be heard and allowed us to share some of the pain and trauma we have experienced.

We were shocked and dismayed when we received the Serious Incident Report, which highlighted the root causes and the areas of improvement. We are relieved that these have been positively addressed as part of the action plan and staff members have been trained further following the death of Isaac and new procedures are in place which will go some way in improving mental health care.”

Sara Lyle of Minton Morrill solicitors, who represented the family said: “The SIR concluded that there was four fundamental factors that had a direct effect on Isaac’s death occurring which included the lack of appropriate consideration and acknowledgement of the nature, degree and severity of the risks that Isaac presented with.  It is regrettable that the Coroner has not identified any failings in his conclusion however, the family are appreciative of the opportunity to seek answers to the questions that they had in relation to the care that Isaac received.”



For more information contact INQUEST Communications Team on 020 7263 1111 or [email protected]; [email protected].

The family is represented by INQUEST Lawyers Group members Sara Lyle of Minton Morrill solicitors.

The other interested persons represented at the inquest were Tees Esk and Wear Valleys NHS Foundation Trust.

For information and advice on how to safely report on self-inflicted deaths, please look at the Samaritans Media Guidelines for reporting suicide and self-harm.