19th September 2016

Two inquests have opened today which highlight trends seen in INQUEST’s casework around the suitability of care being provided to vulnerable adults with serious mental health issues.


  • D’Anna Joan Ward was a 20-year-old young woman with a history of complex mental health problems, including significant self-harming. She was found hanging in her bedroom at her privately run, supported living accommodation on 7th August 2015. In the last 10 months of her life, she visited emergency departments over 20 times and required admission as an inpatient on seven occasions following incidents of self-harming, ligaturing and overdosing. Her family question whether her accommodation was the most appropriate placement to meet her complex needs.
  • Daniel Chapman was a 33-year-old young man living with paranoid schizophrenia, who died as a result of an overdose of a legal high in Bury St Edmunds on 31st October 2014. He had been living in supported housing under the care of Norfolk and Suffolk Mental Health Trust and Julian Support (who provided independent living support). He was susceptible to inappropriate peer pressure and the family felt that he was let down by those responsible for his care.


Deborah Coles, Director of INQUEST said:

“Women, young people and those with mental illness form a high percentage of INQUEST’s casework. Time and again we see inadequate care and support provided to the most vulnerable individuals, in the one place they should feel safe.

These inquests provide an important opportunity to scrutinise what happened to D’Anna and Daniel and to gain insight into how future deaths might be prevented”.

Daniel’s mother, Linda Durrant, commented:

"My son was a very vulnerable young man and reliant on the agencies responsible for his care to keep him safe and alert me to any risks.  I am concerned that I was shut out of the process and there was a failure of communication in this case which prevented me from ensuring my son was not at risk. I hope the inquest answers the questions I have regarding the care and support provided to him”.


Notes to editors:

D’Anna Joan Ward

  • Inquest started on Monday 19th Sept before HMC Michael Singleton, Blackburn Coroner’s Court, Ribble Valley town Hall, Clitheroe. It is estimated to last for 8 days.
  • D’Anna’s family, Bradford District Care NHS Foundation Trust, Lancashire Care NHS Foundation Trust and Prospects Supported Living Ltd are represented at the inquest.
  • INQUEST has been working with the family of D’Anna Ward since November 2015.  The family is represented by INQUEST Lawyers Group members Michael Kennedy and Jim Gladman of Switalskis Solicitors. The family are likely to be available for comment at the conclusion of the inquest.

Daniel Chapman

  • Inquest started on Monday 19th Sept before HMC Peter Dean, Active Business Centre,33 St Andrews Street South, Bury St Edmunds IP33 3PH.
  • Norfolk and Suffolk Mental Health Trust and Julian Support are represented at the inquest.
  • The family is represented by Claire Mawer at 15 New Bridge Street and INQUEST Lawyer’s Group member Harriet Wistrich of Birnberg Peirce Solicitors (0207 911 0166).

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.