Inquest finds defective decisions by Devon mental health services contributed to the death of Keiron O'Sullivan 14 April 2021 Before HM Senior Coroner Ian ArrowTorbay and South Devon Coroner’s Court30 March – 6 April 2021 Keiron O'Sullivan, 64, was declared missing from his home in Devon on 7 December 2018 and found dead three days later in the sea off Portland Bill in Dorset by a fishing boat. He had been under the care of community mental health services from Devon Partnership NHS Foundation Trust until he was discharged in October 2017. Just days before going missing, Kieron was removed from train tracks at his local station and detained by Police following an expression to end his life. A jury inquest into Kieron’s death opened on 30 March 2021 before HM Senior Coroner for Torbay and South Devon, Ian Arrow. HM Senior Coroner ruled that Article 2 European Convention on Human Rights (‘ECHR’) was engaged, allowing the jury to consider ‘how’ and more widely ‘in what circumstances’ Kieron came by his death. The conclusion of the inquest was ‘open’, with the jury unable to determine whether Kieron took an action to end his life. They found that Kieron died from drowning at sea on 7 December 2018, and was suffering from a mental health condition at the time of his death. The inquest also found that there was a defect in the decisions made to safeguard Kieron, and “the removal of a Community Mental Health Team Care Co-Ordinator was an influencing factor in Kieron’s untimely death”. He had a 35-year history of mental ill health, having been hospitalised on numerous occasions, and had been diagnosed with Paranoid Schizophrenia, Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD). In October 2017, Kieron was unhappy to have been discharged from the care of mental health services at Torbay (North) Community Mental Health Team and made several complaints to his treating Consultant Psychiatrist. In January 2018, Kieron was placed in the care of his GP following concern for his mental health. He had been on the waiting list for secondary care psychological therapies, however Kieron did not like to use public transport or to venture far from home, due to his mental ill health. On two occasions he felt physically unwell and unable to travel to Newton Abbot from Dawlish (around nine miles) to attend the assessment. As a result, the Psychological Therapies team closed the referral. Kieron formally complained to the Trust via a complaint letter on 17 January 2018, informing the Trust that he had suffered a period of decline in mental health the same month, yet the decision to keep him closed to CMHT remained following a Care Pathway meeting the following month after a review. PALS responded 10 months later in October 2018 stating that CMHT operates on an intervention and time-limited approach and that Kieron was ‘unable to commit’ to regular therapy. In reality, Kieron’s mental health meant he struggled to attend this away from his locality. On 4 December 2018, Kieron entered onto the train tracks. An oncoming train was able to stop before hitting him, and he had to be forcibly removed from the tracks after telling British Transport Police that he wished to die. Police detained him under Section 136 of the Mental Health Act and took him to a Place of Safety at Torbay Hospital for assessment. He was deemed to be at ‘low to moderate risk’ of self-harm, with a ‘dependent personality’. The locum consultant psychiatrist who assessed Kieron that day, with two other mental health professions, told the inquest that Kieron had expressed to her during the assessment that he did not want to die. She dismissed him as suicidal, stating that standing in front of a train expressing a wish to die was not necessarily an indication of mental ill health. Rather, the psychiatrist was of the opinion that Kieron was making a statement. On questioning, she conceded that it had not been detailed that Kieron had said that he did not want to die, though it should have been, and instead what was recorded was that Kieron was happy that the attempt was unsuccessful. After this assessment on 4 December, it was advised the Community Mental Health Team should make immediate contact with Kieron. They did not speak to him until the following day at 19:55pm. When he told them he was ‘OK’, no further action was taken. On 6 December, Kieron called 999 reporting physical pains in his head and body. He was taken to hospital and referred to the Liaison Psychiatry team, where he was assessed and discharged the same day with no further referral to mental health services. After questions were put to the mental health assessors during the inquest, it was established that a diagnosis they made of ‘malingering’ (when someone pretends to be ill) was subsequently marked as ‘factually incorrect’ within Kieron’s care note records, as this diagnosis did not stand in light of his disappearance a day later. Later that evening Kieron presented at his neighbour’s home complaining of unendurable pain and asking the neighbour to shoot him. The next day, between 7.15 and 9.15am on 7 December, Kieron’s friend called him a number of times and became concerned when she received no reply. She went to his flat and found the door unlocked, and all Kieron’s personal belongings such as wallet and phone in his bedroom, yet Kieron was not there. On 10 December 2018, Kieron’s body was found in the sea in Dorset by a fishing boat. Following the conclusions of the inquest, Kieron’s family, said: “We can only imagine the torment and terror Kieron endured the last week of his life. Kieron should have received help and compassion; instead, he was faced with “Being Challenged” by mental health assessors in his fragile condition, accused of being a liar, not having a mental condition despite his extensive history and presentations and turned away continuously. Regretfully, a Trust member indicated that Kieron was potentially trying to “make a point” when found on the train tracks in front of a train on 4 December. It is extremely concerning that the Trust failed to acknowledge the severity of Kieron’s presentation. Instead, they discharged him to his home just yards away from the train station on the basis that they felt contact from the Crisis team in the community (the next day) would be appropriate to mitigate risk. We heard evidence that the support from CMHT and their caseload had undergone change due to financial pressures and feel that, had the move away from a familiar ‘open-ended guarantee of support’ not taken place, Kieron’s death could have been avoided. We are grateful that the Jury agreed Kieron was suffering from a mental illness and recognised, crucially, that there were defects in the procedures in place and actions taken to safeguard Kieron at the time. We thank our legal representatives for exposing the truth and we hope this will help save future lives of other vulnerable people in the Torbay area, with the Mental Health Trust Services thinking twice before being so uncaring and dismissive. We look forward to hearing exactly what the trust has put into place since Kieron’s death and await their written response as directed by the Coroner.” Niall Robinson, on behalf of Broudie Jackson Canter, said: “It has been a long and emotional process for Kieron’s family and those close to him to pursue these inquest proceedings to a conclusion since his tragic, and avoidable, death in December 2018. We are pleased that the jury identified a central issue in this case; that a gap exists between those requiring the services of CMHT Care and those who are suitable to remain under primary/GP care, and that there was a defect in the procedures in place to protect Kieron in the known circumstances that, ultimately they felt, was an influential factor in his death. We await with anticipation the Trust’s response to what lessons have been learned and actions put in place that means if the same circumstances were to arise again, the outcome will be different. We are glad that the family have obtained answers and a sense of justice and again extend our condolences.” Nancy Kelehar, INQUEST caseworker, said: “It is welcome that the jury have recognised that the removal of a Care Coordinator by Devon Partnership NHS Foundation Trust contributed to Kieron's death. However, INQUEST is involved in too many cases like Kieron's, where a person in crisis has tried to seek help but has been let down by the mental health services and has not received adequate support in the community. There were missed opportunities before Kieron's death which, if taken, may have prevented this tragic outcome. Although the jury's conclusions provide some accountability, fundamental changes must be implemented across community mental health services.” ENDS NOTES TO EDITORS For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected] Kieron’s family are represented by INQUEST Lawyers Group members, Jenny Fraser and Niall Robinson of Broudie Jackson Canter and Catherine Oborne of Garden Court Chambers. The family are supported by INQUEST caseworker Nancy Kelehar. Other Interested Persons represented are Devon Partnership NHS Foundation Trust, Torbay Accident and Emergency, Devon and Cornwall Police, British Transport Police, and the GP. Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.